By Kimberli Frantz, MD
At Lassen Medical Clinic, we field a lot of questions from patients and caregivers about referrals – why they’re required, and how they work. A referral, in the most basic sense, is a written order from your primary care doctor to see a specialist for a specific medical service. Referrals are required by most health insurance companies to ensure that patients are seeing the correct providers for the correct problems. While this may seem to some like an extra, unnecessary step, failure to obtain the necessary referral before seeing a specialist can result in coverage not being applied to a visit or service, and costs being passed on directly to the patient.
The referral process is complex, requiring actions from a variety of entities. Because of this, it’s helpful to understand the considerations and steps that take place after your provider has decided that you would benefit from the expertise of a specialist.
The first question we will ask you is whether or not we have your most recent insurance information on file. This is important because each plan has its own unique set of conditions for referrals. Once we have that information, we can assess if any authorizations are required to allow you to see the specialist. In addition, many insurance plans will only authorize consultations with contracted providers.
After it has been determined that an authorization is required, your provider’s Medical Assistant or Lassen’s Authorization Department will submit the appropriate forms and documentation to the insurer. The insurer will process them and return its own authorization or denial usually within 48-72 hours. Upon receipt, insurer approval and documentation will be forwarded to the specialist. Depending on the insurance company, this process can take up to 14 days.
Specialists often have a process of their own, where they screen referrals for appropriateness clinically. They also must verify that they contract with the insurance company. After this process is complete, they will contact you, the patient, directly to make an appointment.
It is always in your best interest if we have your updated contact information in our electronic record system because that is the information we send to the referring provider. If you have had a recent change of address or phone number, it can delay the referral process. An easy way to check your contact information is to visit your portal account online or to call our office.
Even if you are one of the fortunate ones who has an insurance plan that does not require authorization for specialty care, many specialists will not accept a consult without complete records. These include visit notes, lab and x-ray results. In general, the longer you have had a problem and the more in-depth the workup is, then the longer it can take to collect the data the specialist requires. This is important because you want your appointment with a specialist to be as productive as possible and not repeat tests that have already been done.
It is not uncommon for a specialist to review the case and ask for further tests to be done prior to the consultation. Unfortunately, these very tests may require authorization from your insurer to perform.
Things Patients Can Do:
Tip #1: If you are able to schedule an appointment with the specialist we referred you to, it’s important to make every effort to get to that appointment. Most specialists will not re-appoint you if you have a “no-show”. For those who do miss their appointment, the process above must be repeated, and often options for specialists are more limited the second time around, and require more travel for the patient.
Tip #2: If your provider has told you a referral will be made and you have not heard anything within at least two weeks, please call to check on the status of your referral. Because the process is complex, it can be subject to delays. Your patient care team can look into the referral for you and let you know where things stand.