Gatekeepers
If you may see the primary care doctor as often as you wish, but the plan will not pay for specialists or procedures without a referral from the primary doctor, that doctor is called the "gatekeeper." If your plan assigns you to a single primary care doctor or group, you probably have a gatekeeper.
Some plans have modified gatekeeper systems where you must get an initial referral to a specialist, but then the specialist is able to order tests and have you come back for follow up. Others give you more coverage if you are referred by the primary care doctor, but still give you partial coverage if you aren't.
Many plans exclude certain services, like yearly gynecological exams, from gatekeeping restrictions. Patients can then see doctors in that specialty without needing a referral. Basic needs like vision exams often don't require referrals, either. In some states, plans may not restrict access to gynecologists, pediatricians, or other specialists who also function as primary care doctors.
Choosing a primary care doctor with whom you can see eye-to-eye is essential if you have a gatekeeper plan. But after all, it's important in any plan. If you can't find a doctor whose judgement you trust when you need treatment for a skin rash, what will you do if you are in intensive care on life support? Don't be afraid to switch if you aren't comfortable, and don't wait until you are really sick to think about doing it. The doctor you think is a heartless automaton is probably someone else's dream doctor because she is always on schedule -- it's all a matter of personal preference.
©2000 Eileen K. Carpenter, MD