If you have an HMO can you see a specialist if you do not have a referal?

If you have an HMO you cannot self-refer to a specialist. You must first see your primary care physician (PCP) about the condition. He or she will try to treat you according to medical protocol before sending you to a specialist. Once those efforts are unsuccessful you will then be referred to a specialist. This is true for many conditions such as chronic tendonitis, knee pain, headaches, etc. However, for certain conditions such as broken limbs, post-hospitilization conditions, your PCP will refer you and treat you symptomatically until your appointment. As a side note, specialty visit co-pays are also higher than PCP co-pays.

There are several health plans (insurance companies) that allow self-referrals for certain specialties and for certain conditions. For example, a woman can self-refer to an OB/GYN for an annual well-woman exam. Contact your health plan to find out which specialities/conditions are available for self-referral.

You must try and remember that the purpose of an HMO is to provide good healthcare and contain costs. If your PCP refers you to a specialist without attempting to treat the condition first, the specialist will likely run a battery of tests that may not be needed.