For many of us on plans that require referrals for specialty care, it can be difficult to know if a referral was done properly and/or if the insurance company approved the request for referral.
Many patients assume that, if their primary care physician referred them to a specialist, it is automatically approved by the carrier. This is not always necessarily the case.
There are times when a PCP may refer a patient to a specialist, but only in the form of a verbal referral. For example, the PCP may say to the patient, “I think you would benefit by seeing Dr. __________ for your condition”. Patients often will leave the office, assuming that the actual referral will be done on paper, when in fact, it may not be. It is rare when this happens, but when it does, it can cause much confusion for the patient, and a lot of work trying to obtain a retroactive referral. If too much time has gone by, there is a good chance it is too late to obtain that retro referral.
Another type of referral that must be verified is the “out of network referral”. A PCP may want to refer a patient to a specialist who is not in the patient’s network. If the patient is on an HMO plan, there will be no benefit for that specialty visit without an out of network referral approval. These types of referrals are not always approved. If the carrier can show there is another in network specialist to treat the condition, the request for the out of network provider will often be denied.
This blog post serves a reminder to always check with your insurance company to be sure your referral has been approved. Never assume that because the PCP said they are referring you to another provider, that the referral is approved. The best way to confirm is to call the toll free number on your ID card, and then the rep can verify if your referral is in place.