AAP News Vol. 1 No. 3 March 1985, p. 6
© 1985 American Academy of Pediatrics
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HMO restrictions on outside referrals creates dilemma for practicing pediatrician

Dr. Jones is a pediatrician in a mid-size, Midwestern town who works for a health maintenance organization (HMO).

Last year, he referred a patient to an adult subspecialist on the HMO staff.-Then, because the HMO did not employ a pediatric subspecialist, Dr. Jones referred the patient to a pediatric subspecialist who worked outside of the HMO. The HMO refused to pay for the outside referral and subsequent treatment, claiming that — regardless of the patient's age — only the subspecialist on staff should have been consulted.