Managed care is a system of health care that combines delivery and payment; and influences utilization of services, by employing management techniques designed to promote the delivery of cost-effective health care.

A health maintenance organization (HMO) is a health plan in which enrollees must select a primary care physician (PCP) from a list. This PCP is responsible for a patient's everyday health care needs, including diagnosis, treatment, and when necessary, referrals to specialists.

A primary care physician is usually a doctor in internal medicine, family practice, pediatrics, or, in some cases, obstetrics/gynecology who has ongoing responsibility for the medical care and health maintenance of a patient. The PCP may be selected by the patient from a list provided by the insurer, or may be directly assigned to the patient.

The patient should discuss the need for the visit with their primary care physician (PCP). If the referral is indicated, the PCP can make the referral to the appropriate specialist. It is possible that the PCP can provide what the patient needs, so it's important for them to check with him/her as the first step.

The PCP is a partner in helping the patient navigate the healthcare system. That is why it is important that the patient contact their PCP to discuss any needs they may have for specialty care. His/her knowledge of the patient's medical history and his/her close relationships with specialists and other medical providers allow the PCP to coordinate care.

As a general rule, HMO's will not pay for care from a specialist without a referral. However, each health plan has some exceptions. The patient should be referred to the Member Services department of their health plan to find out what these exceptions are.

If a patient sees a specialist without a referral, they may be asked to sign a waiver form, indicating that they understand that they will be responsible for payment of services rendered.