Certain health care plans require a referral from a primary care physician if members want to see a specialist. If you don’t have to have a referral, your physician is often the best resource for finding the perfect person to help with your health care issues. To get a referral, you’ll typically need to visit your primary care physician first and then ask to be referred to a specialist. But you can research any referral and ask for another one if you disagree with the first choice.
Referral From Primary Care Physician
If you have a medical issue that requires the attention of a specialist, you may be tempted to just make an appointment with your friend’s favorite doctor. Not so fast. With some insurance plans, particularly health maintenance organization and point of service plans, you’re assigned a primary care physician who serves as your point of contact for all of your medical needs, aside from routine gynecological care.
But if your medical insurer allows you to see a specialist without referral, you still may want to consider checking in with your primary care doctor first. Your physician probably knows the medical professionals in your area well. When combined with being familiar with your medical history, you may find that this is the best person to recommend a specialist.
How to Get a Referral
For those on the type of insurance plan that requires a doctor referral for a specialist, you’ll need to go see your primary care physician first. You’ll get a quick lookover, and if your doctor can’t help you, they'll provide the name of a specialist who can help. Some doctors will even make the appointment for you to create that all-too-important paper trail that will ensure your visit is covered.
Whether your insurance requires it or you can see a specialist without referrals, be aware that you do have a say in the specialist you use. If you have someone in mind, ask your primary care physician to refer you there. You can also ask for several names and do some research before agreeing to the official referral. In some cases, your physician may provide a referral based on a phone call, but many providers will require that you come into the office for a consultation first.
When Referrals Aren’t Required
There are some circumstances where you don’t need a doctor referral, including your annual gynecology exam. You can even get a mammogram and Pap smear without your primary care physician signing off on it. Some behavioral health services also don’t require a physician referral but check with your plan to get specifics.
Obviously, if you have an emergency, you won’t need a referral from a primary care physician. It will need to be seen by your insurer as medically necessary, so make sure it falls under your plan’s criteria for that before you go. You can also visit urgent care instead of the emergency room without a doctor’s referral, as long as it’s a medical emergency.
In-Network Doctor Versus Out
One very important distinction, whether you’re getting a doctor’s referral or not, is whether a service provider is considered in-network or out. Some insurers may refer to in-network providers as participating providers. You likely have a website you can consult that lists these providers, but it can be easy to assume that your physician’s referral means the provider is in-network when that isn’t always true.
Even if your insurer allows you to see a specialist without a referral, you need to make sure any specialist you see is in-network. That’s also true if you’re visiting an urgent care clinic or other facility for a nonemergency. Visiting a provider or facility that’s out-of-network could cost you significantly more than you would have paid if you’d checked first.
- Some doctors and medical offices are equipped with the diagnostic machinery or laboratory facilities necessary to perform self referrals. In this case, your doctor may recommend a procedure that she can perform in the office since it means more income for the office and an easier referral process.
- If you are unable to find a doctor willing to make the referral you need, consider making an appointment with the specialist you wish to see and making the payment out of pocket. While the cost may be high, your health is always more important. If the specialist finds a legitimate problem, bring the proof to your primary care doctor, who may then refer you to the specialist so that your insurance will cover any future costs.
- Referrals for special care or medical testing will require a second copay and a visit to both the specialist and the referring doctor.
- Referrals from one doctor to another can often involve kickbacks or other incentives paid to the referring physician. If you ask for a referral or if your doctor volunteers one, she may work from a list of colleagues with whom she has established relationships. These relationships can involve a financial element. If you have a certain specialist in mind, insist on your preferred provider to avoid being taken advantage of.
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