Earlier today, I received a call from Tina, the HR Manager of one of our clients. She asked: “How can the employees maximize the use of our HMO program without increasing the premium cost during our contract renewal? Can you identify some ways on how we can optimize our usage without causing a surge in our utilization?”

 Before I enumerate the ways on how the members can use their healthcare coverage without causing an increase in renewal costs, let’s define some terms first. HMO or Health Maintenance Organization is the company that provides access to its network of hospitals, clinics, and doctors. HMOs guarantee the payment of the services obtained from their network as defined in the contract. There are two main types of HMO programs: Premium-Based and Third Party Administration (TPA). The former is the insurance type where 100% of the risks are shouldered by the HMO provider while the latter is the complete opposite where it is a self-insurance program and 100% of the risks are on the hands of the employer. But regardless if it’s Premium-based or TPA program, an improper use of the healthcare benefits can lead to increase in costs.

So, how do we maximize the benefits without increasing the costs? Follow these tips below:


PCC’s are HMO-owned clinics that has access to primary care doctors and basic laboratories. Most HMO providers give free unlimited consultations from their own PCC’s to encourage members. The laboratories are also cheaper in PCCs than in the hospitals. Thus, by using PCC’s, the members can help lower the utilization costs. It is also wise to go through the PCC’s first so members avoid depleting their benefit limits and reserve them for other more dreaded conditions.

Some of the services available at these PCC’s are:

  • Consultations with Internal Medicine, OB-Gyne, and Family Physicians.
  • Simple laboratories like: X-ray, blood chemistries, urinalysis, fecalysis, etc.
  • Medical Certificates to be submitted to employer during prolonged sick-leaves (case-to-case basis).
  • Pre-employment medical exam (PEME)
  • Dermatology procedures (some HMO’s only)


Some members prefer to go for consultations beyond the regular clinic hours. Thus, they are directed to proceed to the Emergency Room (ER) instead. Consultations done in ER are charged as much as 3-5 times more expensive as compared to a consultation done at the doctor’s clinic. Regular clinic hours are usually between 9am to 5pm.

Based on the cases being brought to ER, more than 65% are NOT emergencies. Therefore, these are causing unnecessary utilization and thereby increasing the medical costs. The solution is to convince the employees and their dependents to go for consultation during the regular clinic hours to avoid this unnecessary expense.


As the old adage would have it, prevention is always better than cure. This is still as relevant today especially with the advancement of medicine. An early detection of an illness would help the members avoid complications and expensive medical procedures for truly advanced cases. It is best to require the employees undergo Annual Check-ups to diagnose possible illnesses.


Employers who want to control their utilization would restrict their members in using the major hospitals. It is true that major hospitals would be 2-3 times more expensive than that of clinics and regular hospitals. Thus, restricting the access to major hospitals can help lower the medical utilization cost of the entire company. Yes, we all prefer to go to major hospitals due to its perceived superior quality of equipment and services but the other less popular hospitals are actually at par with most major hospitals nowadays.


It is recommended that we conduct a review of the medical utilization every quarter. This is to ensure that we monitor the potential increase of claims and to check if members are properly using their HMO benefits. By reviewing the utilization regularly, we can identify illnesses that may get worse over time or progress to a more advanced stage which would eventually lead to higher medical costs. For example, an uncontrolled hypertension may lead to complications like stroke, heart attack, kidney failure, and other dreaded illnesses. Thus, upon seeing the prevalence of hypertension, your benefit consultant will recommend possible wellness programs to help the members manage their condition.

Another advantage of a regular utilization review is for budgeting purposes. If we are aware of the total claims, we will be better equipped to make plans for our future healthcare program.

So, we can help you manage your medical costs while optimizing the benefits of your HMO program, let our expert Benefit Consultants guide you.

For inquiries and free consultation, please get in touch with us at +632-6555026 or +639189856931. Or email us at support@keymaninsurance.ph.