Insurance_Referral_vs_Provider_Referral

Insurance Referral vs. Provider Referral Teresa Yates Rasmussen College Author Note This written assignment is being submitted on February 15, 2013 for Laura Lee’s M200/OST1461 Section 01 Medical Office Procedures class. A doctor's referral is a request for services, and is often called a consultation request. It is also a correspondence from one doctor to another stating treatments, medications, history or illnesses/conditions that have been tried on a patient prior to being referred to a specialist office. A patient can’t decide on their own that they want to go see a specialist for whatever medical issues they may be experiencing. A patient must have a visit with their primary care doctor and then obtain a referral to a specialist once the primary care doctor determines that the medical issue the patient has is out of their scope. The patient then gets referred to a specialist, someone whom is specialized in a specific scope of practice, for further evaluation. An insurance referral is a requirement of a managed care insurance company. If a patient has Managed Care insurance, such as an HMO, they will always need an insurance referral to be seen by a specialty department. The insurance referral is written by the patient's primary care physician. If your medical condition requires the attention of a specialist, the family doctor may recommend the patient see a specialist. This is known as a referral. Since the PCP has a broad perspective on the patient’s health, he or she will share information about related conditions, tests, or health risks with the specialist. It is important for the PCP to contact the patient’s insurance company to see if the patient does need a referral to go to a specialist. It’s important to find out if the patients insurance will pay for them to visit with a specialist. With the information that is provided to the insurance company, they will then determine if treatment from a specialist is necessary and how much, if any, they are willing to pay. It’s also important not to schedule an appointment with a specialist until the primary physician has found out if the patient’s insurance will pay or not. If the insurance company doesn't authorize a referral, then most insurance plans have a procedure for the patient to appeal that decision. References Lindh, W., Pooler, M., Tamparo, C., Dahl, B., (2010). Medical Insurance. Administrative Medical Assisting; Unit 4 Integrated Administrative Procedures. Clifton Park, NY Stanfield, C. (2011). Physician Billing Services - Frequently Asked Referral Questions. In WellSpan Health. Retrieved February 13, 2013, from http://www.wellspan.org/body.cfm'id=673.