Trying to figure out which healthcare provider to see for a particular problem or condition can be confusing. While some insurance companies require patients to seek a primary care referral to a specialist, more and more insurance companies are removing this restriction, allowing patients to choose their own specialists with little or no restrictions.
Without a healthcare insider guiding them, patients may not know what type of specialist to contact or what services they need to address a particular health issue. This kind of self-referral can end up costing the patient time and money. Without guidance, patients often go from doctor to doctor, incurring co-pays and other out-of-pocket costs while experiencing delays in diagnosis and treatment.
If you’re wondering, “how do referrals work?” we are here to explain all you need to know, including:
- Patient referral meaning
- Why referrals can be beneficial
- When referrals are necessary
- The process of obtaining a referral
- The part insurance plays in the doctor referral process
What is a Patient Referral?
Generally speaking, a patient referral is a communication from one health care professional to another — usually a specialist of some kind — requesting that they accept you as a patient to evaluate your condition, provide a diagnosis, and/or provide treatment.
A referral serves several purposes.
- It ensures that the physician or health care provider is aware of the service requested and is prepared to provide it to you.
- It streamlines new patient paperwork as your medical history and other background information are usually provided with the referral.
- It makes patient intake, including processing insurance authorization matters, a smoother process for all involved.
When are Referrals Necessary? And Why Do I Need a Referral to See a Specialist?
Usually, referrals from doctors are recommended to ensure you receive the right care from the right health care specialist at the right time. The question, however, when are patient referrals needed will depend on your insurance policy terms.
Your primary care provider (PCP) is usually your first line of defense when it comes to your healthcare. Typically an internist, general practitioner (GP), family medicine physician, pediatrician, physician assistant, or nurse practitioner, your PCP is the person you go to first when you have a medical complaint or are seeking a check-up. While PCPs are trained to take care of most routine health matters, they will sometimes determine that another practitioner can best handle a particular issue. In situations like this, they will refer you to another provider.
Sometimes doctors’ referrals are made for routine preventive care — such as being referred to a lab for a blood draw. Other times, medical referrals are for diagnosis and treatment. For instance, if you are experiencing ongoing foot pain, your PCP might refer you to a podiatrist or an orthopedist specializing in foot and ankle issues.
Often, patients request that their PCP refer them to a specialist. They may prefer seeing someone that the PCP knows and trusts — rather than relying on word-of-mouth referrals from friends or Google reviews — and they might need the referral to be in-network with their insurance company to pay for the visit.
What is the Patient Referral Process?
So how long does it take to get a referral from a doctor? And what is the process like? Depending on your insurance provider’s requirements, the typical primary care to specialist referral process goes something like this.
- You consult with your PCP about your need for a referral. This conversion may be initiated by either your doctor or you, depending on the reason for the referral.
- Your PCP determines the type of specialist that will best meet your needs. Often, this will be someone in their practice network, someone they have worked with before, and/or someone you have had a prior relationship with or have a preference to see.
- Your PCP’s office will send a referral form to the specialist, which typically includes your relevant medical records, the reason for the referral, and, where applicable, the parameters of treatment. For instance, you might be referred for eight weeks of physical therapy to manage shoulder pain. In some instances, a care navigator can book an appointment for you.
- After your visit for diagnosis, treatment, or therapy, the specialist will send a report to your PCP detailing the results of your visit, your diagnosis, if applicable, and their recommendations, if any, for follow-up or further treatment. This type of communication ensures that you have continuity of care.
How Do Referrals Work Under Different Insurance Plans? Does Insurance Cover Provider Referrals?
Whether, to what extent, and how your insurance plan covers or requires referrals depends on the type of policy you have and the details of the particular plan. The following provides, in general terms, an overview of how different types of insurance plans treat physician referrals.
- HMO and POS network plan. If you are on an HMO (health maintenance organization) or POS (point of service) network plan, you will likely be required to obtain a PCP referral before seeking the services of a specialist. The plan would have assigned you a PCP when the plan took effect. Check with this provider before proceeding with a specialist, or you may have to pay for the visit yourself.
- PPO or EPO network plan. Suppose you are on a PPO (preferred provider organization) or EPO (exclusive provider organization) network plan. In that case, you can probably seek specialist services on your own without requiring a referral. However, you must choose a provider in your plan’s network if you want to take advantage of lower costs and co-pays. Out-of-network providers can be costly, and some may not be covered under your plan.
- Original Medicare (Part A, Part B). As long as the provider accepts Medicare, your specialist visit will be covered under Parts A&B.
- Medicare Advantage (Part C). Be careful when choosing a physician under Medicare Advantage plans. Many of these plans operate like HMOs, so you need a PCP referral to see a covered specialist. Others operate like PPOs, so you can choose your own provider, but you will want to ensure they are in the specified plan network. Under some private fee-for-service plans (PFFS), assuming the doctor accepts Medicare, you will have to pay up to 15% of the charges out of pocket.
Eden Health Takes the Guesswork Out of Referrals
Understanding how referrals work is key to obtaining the healthcare you need without breaking the bank by inadvertently running afoul of insurance referral rules or going to an out-of-network provider. The last thing you should have to worry about, especially if you are in a medical crisis, is how to find an in-network referral, schedule appointments, and review bills and insurance to make sure everything is in proper order.
Eden Health takes all of these burdens off members’ shoulders by providing the services of expert Care Navigators. These compassionate professionals are an integral component of an employee’s Care Team and bring the same level of devotion to employee health and financial wellbeing as their clinical counterparts.To learn more about Eden’s services, including how our Care Navigators help manage referrals, visit us online to request a demo.
This blog is intended to be informational in nature. The information and other content provided in this blog, or in any linked materials, are not intended and should not be construed as medical advice, nor is the information a substitute for professional medical expertise or treatment.
If you have any questions or concerns, please talk to your Care Team or other healthcare provider. Never disregard professional medical advice or delay in seeking it because of something you have read on this blog or in any linked materials.