What is the Purpose of a Medical Referral?

Some health insurance plans require referrals in order to see doctors other than your primary care doctor. However, it can be wise to seek out medical referrals before seeking new doctors even when this is not the case.

Far from popular misconception, insurance plans requiring referrals is not just a scam meant to make insurance companies and doctors rich. Quite the contrary, it could be argued insurance companies and doctors could make more money if patients were allowed to see whomever they wanted whenever they wanted. Rather, the purpose of medical referrals is to offer patients the best and safest overall health care management possible.

A referral system ensures one doctor oversees all your care as well as giving the team of other doctors working in that effort full awareness of your medical history. Referrals also help ensure you get the right care at the right time for the health concerns you face. In addition to making referrals to medical specialists, doctors can also make referrals to skilled nursing facilities, hospitals, durable medical equipment providers and others involved in your total health care. The following can help you understand the vital role that medical referrals play in the American healthcare system.

When Referrals Are Required

If the type of health insurance plan you have requires you to get a referral from your primary care physician before seeing any other doctor, then you must always run any and all health concerns through your primary doctor first. One clear and obvious benefit of this requirement is that it ensures the sole doctor responsible for your overall primary care is aware of all issues and treatments relating to your health. In other words, it keeps issues you may have from falling through the cracks until they become greater problems.

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Having a single expert source aware of everything involving your health can give you the best chances of maintaining and improving that health and avoiding setbacks. An example of a setback could be a misdiagnosis because of a specialist’s unawareness of an existing health condition or a medication interaction or reaction because a specialist was unaware of all the medications you are taking or particular relevant allergies.

Doctors in HMO plans and other insurance programs requiring referrals are part of a whole network of doctors in all the various specialties who are also in that plan. As such, these doctors not only offer the quality control and assurance that comes from the plan’s oversight, they also communicate with the other doctors in their network. This way all doctors involved in your care can have a conversation about your care while all on the same page, ensuring each one is doing his or her part to contribute to the same singular overall health care plan on your behalf. The alternative to this is each doctor seeing only his or her part of the picture and ignoring its impact on your overall total wellness.

 Note that, even though medical referrals may be required by your health insurance plan, you still have the power and right to refuse a particular referral and request another one. If, for any reason, you decide that you do not want to work with the specialist or use the facility your primary doctor referred you to, then go back to your primary doctor and request a referral to another one. There is a reasonable limit, of course, to how many times you can do this before your primary doctor runs out of options in his or her network to give you, but, barring that, you have the right to choose the path of your own health care.

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In fact, you could even go outside your primary doctor’s network for care if none of the referrals given suited you. However, you will likely have to pay for that portion of your care out of your own pocket instead of your insurance company paying for it. In order to be sure that your insurance company indeed pays for any referral provided by your primary doctor, make sure your insurance company has received the referral before you have your appointment with the given specialist or check in at the given facility.

When Referrals Are Recommended

Even when your health insurance plan does not require you to get a referral before finding a doctor, it can be wise to do so. Whether in a health network or simply part of a local health care community, doctors in one specialty often know other doctors in the area in other specialties. Moreover, doctors hear stories from patients about their experiences with other doctors. While these conversations are confidential, the revelations they impart cannot go without impacting one doctor’s professional impression of another.

Furthermore, even if a doctor is unaware of recommended specialists in a particular area, he or she can often help you locate one likely to serve you well by lending a trained eye to your research efforts. All of this is to say that one doctor can be an invaluable ally in helping you find another doctor who can help you with a particular concern.

Seeking referrals of specialists from your primary care also serves several other benefits, including the following:

  • Protects you from charlatans and doctors who have lost their licenses to practice medicine
  • Saves you money wasted on seeing the wrong type of specialist for your particular concern
  • Finds a health care provider closer, more affordable or more appropriate for your unique needs than the one you may have found on your own
  • Saves you from seeing a specialist when your primary doctor was already perfectly capable of helping you resolve the concern for far less time, money or hassle
  • Keeps your primary care doctor in the loop when a specialist whom he or she recommends you see, in turn, refers you to another specialist

When referrals are required through your health insurance plan, a specialist is not permitted to refer you to another specialist. You must seek out this referral, too, from your primary care doctor.

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