Pre–Certification:
1.    Before physician can treat a patient, the HMO must review how the patient will be treated, and the HMO decides if they are going to pay for such treatments.
2.    HMOs often have their own set of guidelines.
a)    Example would be a patient who has a back injury and back pain and in absence of specific findings by the doctor, the rule is that you cannot get an MRI of the lower back unless the pain has gone on for more than 3 weeks, etc.
3.    First issue is whether the care will be paid for, and thus will it be provided?
4.    Second issue is how much will be provided.
5.    Created a lot of tension between doctor and patient b/c HMO may not allow for service.  Doctor has to tell the patient that HMO won’t pay for it, so if patient wants surgery, patient himself has to pay for it.