The HMO Referrals Solutions Workflow – How To Get Your HMO To Work For You

The HMO Referrals Workflow Most Seniors Don’t Know About

Let me share a secret with you, one that I’ve passed along to many of my clients, and one that has saved them weeks (sometimes months) of frustration waiting on referrals.

If we haven’t worked together yet, consider this my way of introducing myself.

I’m Jordan Shanbrom, and I’ve spent 13 years helping people in the Antelope Valley navigate Medicare and retirement planning.

One of the things I’ve learned along the way is that the HMO system, while it can be incredibly valuable, doesn’t always run on its own the way it should.

Here’s the honest truth: HMOs are systems run by people, and people, as wonderful as they are, make mistakes.

They forget to send a fax. A referral slips through the cracks. A request gets lost between the doctor’s office and the medical group.

If you sit back and wait, assuming everything is being handled, you may be waiting a very long time.

The good news? There’s a simple, step-by-step approach that puts you back in the driver’s seat.

Step 1: Come Prepared to Every Appointment

Before you go to your doctor, write down every referral you need whether it’s for dermatology, podiatry, cardiology, or anything else.

When you’re in the office, bring two copies: one for yourself, and one to hand directly to the doctor or nurse.

Why the extra copy?

Simple.

It removes any chance of the office saying later, “I don’t remember you asking for that.”

You have your list, they have theirs.

Everyone is on the same page.

Step 2: Follow Up with the Doctor’s Office

This is the most important step, and the one most people skip:

Don’t wait for them to call you.

Sadly, some offices are far too busy to offer this type of follow up and others wouldn’t offer it at all.

• If your referral is urgent, call the front desk every 1–2 business days.
• If it’s routine, call every 3–5 business days.

A friendly call goes a long way each time. Something like:

“Hi Jane, this is [your name]. I just wanted to check and see if Dr. Gill was able to send in my X-ray referral.”

That’s it. Short, polite, and effective. Most of the time, a call or two is all it takes.

Even after the 3rd time, please keep your friendly tone.

I’ve never seen a client succeed with an angry or rude tone, if anything it has the opposite effect that you’re looking to achieve.

Step 3: Contact the Medical Group’s Referral Department

If you’ve followed up two or three times with the doctor’s office and still don’t have a resolution, it’s time to go one level up.

This can be because the doctor’s office has reached out to the referral department multiple times, or they’re not sure what is missing to get the authorization going again.

In either case, it is time to move up the chain.

Call your Medical Group’s referral department.

You can either get this number from the front desk receptionist at the doctor’s office, on Google, or on their website.

Don’t feel bad about dropping in for a face to face chat, sometimes calling isn’t enough.

Either way, call or contact them and ask the following two things:

1. Have they received the referral request from the doctor’s office? If yes: what is the current status? If no: ask the doctor’s office why it hasn’t been sent yet, and restart Step 2.
2. If you have the authorization, what is holding back approval? Is there a missing CPT code, an incorrect CPT code, or is there a missing step that hasn’t been done first?

(side note: This is what a CPT code is: The Current Procedural Terminology (CPT®) code set is a listing of terms and five-digit codes that primarily describe medical services and procedures performed by physicians and other qualified health care professionals. Want to learn more about the types of CPT codes and how it all works? Be my guest and click on the link)

The medical group is the link between your doctor and your insurance company. Contacting them directly often shakes things loose quickly.

And surprise surprise! You might have to follow up with the Medical Group in the same manner as you would the doctor’s office.

Because the Medical Group is made up of people that make mistakes and are not perfect.

So you will have to follow up and the same schedule of follow up is required if you want to be proactive:

• If your referral is urgent, call the front desk every 1–2 business days.
• If it’s routine, call every 3–5 business days.

Typically, at this stage of the process, I would say over 50% of my clients will have a solution, and you will feel even better about the power you have to control your healthcare.

Step 4: Contact Your Insurance Company

However, ff after two or three attempts, and the Medical Group still hasn’t resolved the issue, it’s time to bring in the insurance company directly.

Call the member services number on the back of your insurance card and explain the situation calmly and clearly.

Let them know what’s been happening and ask for their help.

Give them the documented timeline of when the issue started, who you’ve contacted, and what needs to be done.

At this stage, most issues get resolved. The insurance company has authority that the medical group doesn’t, and a phone call from a member tends to get attention.

Within 3-5 business days, the insurance company usually resolves the situation, and I’ve had clients tell me how impressed they were that this was handled so well with the insurance company.

Why Following Every Step Matters, Even When It Feels Repetitive

I want to pause here for a moment, because this part is important.

Each time you make a call, write down the date, the name of the person you spoke with, and a brief note about what they told you.

It doesn’t need to be fancy, a notepad on the kitchen counter works just fine.

Here’s why this matters: if your situation ever reaches the point where I need to step in and escalate to the insurance company’s executive team, I can’t just call or email them and say:

“My client isn’t getting their referral, and you need to fix it for them.”

That won’t move the needle.

What does move the needle is walking in with a clear, documented record including dates, names, what was promised, and what didn’t happen.

That transforms your situation from a complaint into a case, and executives take cases seriously.

Every step you take isn’t just you trying to solve the problem on your own. It’s you and I building the evidence together, so that if we need to go to the top, we go in prepared and we win.

Step 5: Call Your Medicare Broker

In rare cases, and I do mean rare, even the insurance company doesn’t move fast enough or they themselves aren’t able to figure out the problem.

That’s where I come in.

When a client calls me at this stage, I go straight to the executive team at the insurance company.

I present the situation along with the documentation of every step my client has already taken. The executive team does not like hearing that the system has failed one of their members.

They act quickly, and they make sure the problem gets solved.

This isn’t a bluff or a last resort, it’s a real tool, and it works. But it works best when we have the paper trail to back it up.

Step 6: The Final Solution: Filing A Grievance

If contacting me to get to the executive team was a rare occurrence in this workflow, then this last step, would be the rarest and final step.

Filing a grievance against the cause of your healthcare problem(s) is a grave action that has major consequences for the source of your problem(s).

For the doctor’s office:

They will be disciplined by the insurance company, first by being educated on how to not let it happen again, and after numerous grievances, they will have their quality measures affected negatively which affects how much the insurance company pays the doctor’s office.

I don’t know about you, but losing income over not solving an issue isn’t worth it, most doctors would agree.

For the medical group:

Even receiving one grievance is damaging.

The insurance company will have to pass down the financial penalties they incurred because of the mishandling of healthcare by the medical group.

Not only that, but the medical group will be hit with a lowering of their Star Ratings, which is a big deal for income from the insurance companies and the federal government.

For the insurance company:

Grievances are severe.

Starting with financial penalties, and after repeat grievances, the federal government will sanction their insurance plans, which means that their plans can’t be enrolled by brokers like me until the insurance company takes the correct actions to resolve the issue.

Finally, if they are tripping over tables constantly and hurting a large population of members, the federal government will shut down the contract with the insurance company, effectively putting them out of business.

I’m sure by now, you can see how grave a grievance can be.

How do you file one?

1. Start by calling the insurance company and filing it directly with them against whoever the source of the problem is (i.e. doctor’s office keeps using the wrong CPT codes, medical group keeps sending the referral to the wrong specialist office delaying your healthcare, etc). Including the insurance company themselves, start a formal grievance with them first, and if it seems like they are dragging their feet with resolving the cause of the problem, move to step 2
2. Contact and file a grievance with the Center for Medicare and Medicaid Services (CMS) who manage the federal side of Medicare and are your watchdog when it comes to advocacy and protection against fraud, waste, and abuse (not getting access to necessary healthcare is considered a form of abuse).
3. Follow up in 45 business days to check for the result of this final grievance.

A Quick Summary of the Roadmap

1. Write down your referrals before your appointment and give a copy to the doctor’s office.
2. Follow up with the doctor’s office every 1 to 2 days (urgent) or 3 to 5 days (routine). Write down who you spoke with and what they said.
3. If unresolved after 2 to 3 attempts, contact the Medical Group’s referral department. Keep notes.
4. If still unresolved, call your insurance company’s member services. Keep notes.
5. If all else fails, contact your Medicare Broker, who will use your documented steps to build a case and escalate to the insurance company’s executive team.
6. As a last resort, file a grievance with the insurance company and, if needed, with CMS.

Many of my clients who have followed this roadmap have been genuinely surprised by how well it works and how much more smoothly their HMO experience becomes when they take an active role in their healthcare management.

You are not just a policy number. You are a member with rights, and the system is supposed to work for you. Sometimes it just needs a little nudge.

I have more tips like this one, insights I’ve picked up over 13 years in the insurance industry that I love passing along to the people I work with.

If you’d like to talk about your Medicare coverage and/or your options, I’d love to connect.

To schedule an appointment, visit my calendar here.

Prefer to talk to a real person? Call my assistant, Irene, Monday through Friday between 9:00 AM and 3:30 PM at 661-400-9284 and she’ll get you set up.

Looking forward to working with you.

— Jordan Shanbrom, Medicare & Retirement Specialist | California Life Coverage