HMOs------Pcp Referal Needed Process

[yabadabadoo1026]

Anyone know the ins- and --outs on referals to specialists. Are the mechanics of such defined anywhere as vagueness will certainly cause problems and complaints. ie

1) is a new referral needed for every followup visit to a specialist or will
the initial referral have a time frame or a defined number of follow-up
visits to specialist that don't require another referral???-if it 1 referral
per specialist visit ?

for example----pcp writes referral to cardiologist----he does his
thing and says I need to see you back in in 4 months to followup
exam----can this f/u happen directly via specialists instructions
or does this guy have to have another office visit to pcp just to
get a referral? Someone isn't going to be happy if a pcp nixes
the referral by not giving one-------does this actually happen?????
Will a PCP write a referral over the phone rather than having to
have another office visit to get it?

2) are any carriers HMO referral policy or mechanics easier and more
liberal than others---------I fear moving someone from a PPO now
with a premium to a $ 0/mo HMO and them not following referals
requirements to a T since its not defined in detail anywhere. I know
the HMOs want the referral but do they really enforce it that strictly--
if so I bet they dealing with complaints regularly on unpaid
claims even though the member has been told the referral rules--
vague and undefined as they seem to be

 

[unic.consulting]

Anyone know the ins- and --outs on referals to specialists. Are the mechanics of such defined anywhere as vagueness will certainly cause problems and complaints. ie

1) is a new referral needed for every followup visit to a specialist or will
the initial referral have a time frame or a defined number of follow-up
visits to specialist that don't require another referral???-if it 1 referral
per specialist visit ?

for example----pcp writes referral to cardiologist----he does his
thing and says I need to see you back in in 4 months to followup
exam----can this f/u happen directly via specialists instructions
or does this guy have to have another office visit to pcp just to
get a referral? Someone isn't going to be happy if a pcp nixes
the referral by not giving one-------does this actually happen?????
Will a PCP write a referral over the phone rather than having to
have another office visit to get it?

Most insurance companies will allow up to 6-8 visits on a referral if the doctor authorizes it. The idea is that the PCP knows that the patient is seeing a specialist and who they are seeing. If the patient goes to a specialist, then lets their PCP know, then, yes, the PCP may not give the referral, but usually as long as it makes sense for the patient's health, then a referral will be given.

2) are any carriers HMO referral policy or mechanics easier and more
liberal than others---------I fear moving someone from a PPO now
with a premium to a $ 0/mo HMO and them not following referals
requirements to a T since its not defined in detail anywhere. I know
the HMOs want the referral but do they really enforce it that strictly--
if so I bet they dealing with complaints regularly on unpaid
claims even though the member has been told the referral rules--
vague and undefined as they seem to be

Most referral processes are fairly standard as long as the office does them online. It really depends on the doctor's office which ones are easiest. The most important thing is that they let their PCP know before they go see the specialist.

 

[larymes]

There are very few hmos that actually allow you to go to a specialist or any dr in the network without a referral. This is a huge liberty for a hmo to have. But you have to find which ones in your area. If any

 

[BobbyMcGee]

I've seen this all over the board. Some PCP's will bend over backwards to recommend a specialist/ specialists that you can go to and even make the appt. for you. Some others will not help at all, and I actually had one tell the client to "look it up in his book". Unreal. Had a case where the Specialist wouldn't treat until he got a referral, so there must be some responsibility on their part.
I tell the client this is when they have to be a little proactive and check out the specialist on healthgrades or whatever, and make sure they get the referral, altho I've never seen any repercussions from not getting one.

And you don't need a referral every time. And if you did need a new one to the same doc, his office would take care of it.