Referral Management FAQs

Why do I have to check with my primary care physician (PCP) before seeing a specialist?

The primary care physician’s (PCP’s) role is to be the overall coordinator of your care. Because your PCP knows your complete medical history, he or she is best able to identify your health care needs and coordinate your care. If you and your PCP decide you need to see a specialist, your PCP will refer you to a specialist who is:

  • Someone that your PCP trusts to treat your specific condition
  • Often affiliated with the same hospital or referral circle as your PCP so that your latest charts, X-rays and test results are easily accessible, and care can be well coordinated for you and often more convenient to you

What happens if I see a specialist without getting a referral?

As a general rule, if you have an HMO or POS plan your insurer will not pay for care from a specialist without a referral from your PCP. There are exceptions – following are types of care that may usually be obtained without a referral:

  • OB/Gyn services provided by participating obstetricians, gynecologists, OB/Gyn Nurse Practitioners and certified nurse midwives
  • Annual eye exam
  • Emergency care for all managed care members – patients are encouraged to contact their PCPs within 48 hours of their ER visits

"What if my specialist recommends I see another specialist?"

You should always check with your PCP before seeing a Specialist.   Your PCP has responsibility for overseeing all of the care you receive and can help you see the specialist that is right for you.   A referral may be necessary and your PCP will coordinate the appropriate authorizations.

I’ve been seeing the same specialist for several years, and my PCP referred me to a different specialist. Why do I have to change specialists now?

Your PCP will only refer you to specialists with whom he or she is affiliated, unless there is a clinical need to go elsewhere.  The specialist is usually at the same hospital or in the same referral circle as your PCP.

What if I need a second surgical opinion?

You do have second opinion benefits under your HMO plan—and this would be coordinated through your PCP’s office using the qualified providers within your PCP’s referral circle. You can discuss your needs and expectations with your PCP and then determine which specialist you should see.

  • You must first talk to your PCP to get a referral for a second opinion.

 

What if I disagree with my PCP's decision not to refer me to the specialist of my choice?

If you are concerned about a health care decision, discuss your concerns with your PCP.  Your PCP is the doctor who knows the most about your health and medical history -and wants to help you get the right care. They also want to make sure your care is well coordinated and that there is good communication among the doctors you see. Having your PCP coordinate your care helps avoid medical errors that can occur when specialists may not be aware of prior test results, your current medication, important medical history, allergies and other risk factors you may have. Your PCP will also know what’s important to you and your family in your health care decisions and can advocate for you. So continuing to work with your PCP helps the PCP to get to know you better and help you more effectively, and helps you develop mutual trust.

  • Payment for specialty care is made only when your PCP refers you to that specialist.

Does my PCP have a financial incentive to limit my care? Will I be denied services?

No. There are no financial incentives to limit care. However, there are incentives that reward your PCP for good quality of care, such as making sure that you are getting the tests and services you need to maintain good health and to carefully care for chronic illnesses. Also, your PCP, like all physicians, wants to help you get the right care, at the right time, and in the right setting. Your PCP wants to make sure that you get what you need quickly and efficiently, often in your community, and they want to help you avoid tests or procedures that may not help you and may even potentially harm you. Your PCP is part of a group of doctors that has agreed to be reimbursed based on how well they take care of a large group of patients rather than for how many tests, visits and procedures they perform. They are accountable for the quality of care for each patient, for the efficiency of care for the whole group, and for the positive experiences of the patients cared for by the group.

How will I know the specialist is a good doctor?

Your health plan reviews physicians’ education, work experience and other background information to make sure he or she meets stringent professional and technical standards for participation in their plan. We repeat this evaluation process, called re-credentialing, every two years for each participating managed care physician in our network. Your PCP will know the specialists they refer you to even better and can tell you more about them.

Will all medical care automatically be covered?

Not necessarily. It all depends on your plan’s coverage. If, for example, your plan doesn’t cover prescription drugs, then you will have to pay for medication yourself, even if your doctor recommends it. And some services or items may not be covered by your plan, such as orthotics, even though your doctor may recommend them. Read your subscriber certificate carefully to find out which services are covered and which are not covered. If you still have questions, contact your health plan’s toll-free 800 number on your member identification card.