Why would a referral be required?

[pjohns]

I am still trying to figure out just why a specialist--a doctor--might require a referral from a PCP (unless one is already an established customer with that specialist).

That makes absolutely no sense to me.

Any thoughts on the matter?

[Standing Wolf]

I am still trying to figure out just why a specialist--a doctor--might require a referral from a PCP (unless one is already an established customer with that specialist).

That makes absolutely no sense to me.

Any thoughts on the matter?

I can only imagine that it's a matter of the insurance company requiring the referral, either as a general rule or in the case of that particular ailment or complaint.

[carolina73]

Insurance companies generally require it. They don't want hypochondriacs and involved with self diagnoses running off to specialists. The specialist wants to make sure they are going to get paid and are not clogging up their schedule with people that don't need them.

[Standing Wolf]

I'm fortunate not to have that problem. I've had hip and leg problems for some time, so I called an orthopedic specialist this morning and made an appointment for Thursday. No referral necessary. The same folks performed my wife's back surgery earlier this year, and she didn't require a referral, either. Consultations, hospital, surgery and an incredibly nice rehab facility afterwards, and not a penny out of pocket. Medicare and the insurance from her postal retirement took care of it all.

[carolina73]

I'm fortunate not to have that problem. I've had hip and leg problems for some time, so I called an orthopedic specialist this morning and made an appointment for Thursday. No referral necessary. The same folks performed my wife's back surgery earlier this year, and she didn't require a referral, either. Consultations, hospital, surgery and an incredibly nice rehab facility afterwards, and not a penny out of pocket. Medicare and the insurance from her postal retirement took care of it all.

Being a big retirement area but a lower population we have the problem. If you think you have skin cancer then you wait 6 months for appointment. People drive 2 hours to get the right type of eye doctor. I had a friend that needed his prostrate treated and he had to drive 7 hours to Jacksonville, FL to have a modern procedure.

So no referral = no service.

[Peter1469]

I am still trying to figure out just why a specialist--a doctor--might require a referral from a PCP (unless one is already an established customer with that specialist).

That makes absolutely no sense to me.

Any thoughts on the matter?

It depends on what type of insurance you have. HMOs operate through your primary care provider. They give you referrals for specialists.

POP insurance doesn't work that way. You can go to any doc in your network. These plans cost more and if you go outside your network you pay much more and maybe 100%.

[Peter1469]

The primary care system is dying. General practitioners/family docs are near the bottom of doc pay, so many new docs avoid those fields.

Many people don't bother with annual checkups anymore. What is an annual check up these days? Where I go you sit in the waiting room (after your appointment time) longer than the appointment takes. A nurse weighs you, gets your height (so the computer can calculate your BMI) and then draws your blood. You then wait in a room until the doc shows up to do almost nothing. Then it is over. When the blood test results come back, you are good, or you are not. Since I have a POP my doc will just say if something is screwy. Then it is up to me to find a specialist. If I had an HMO she would give me a referral to who her office picked.

My primary doc moved to another job. I may just sign up with CVS to use them as primary for blood tests. I can read a blood test. If something is screwy I can handle it from there w/o a primary doc.

[slideman]

The primary care system is dying. General practitioners/family docs are near the bottom of doc pay, so many new docs avoid those fields.

Many people don't bother with annual checkups anymore. What is an annual check up these days? Where I go you sit in the waiting room (after your appointment time) longer than the appointment takes. A nurse weighs you, gets your height (so the computer can calculate your BMI) and then draws your blood. You then wait in a room until the doc shows up to do almost nothing. Then it is over. When the blood test results come back, you are good, or you are not. Since I have a POP my doc will just say if something is screwy. Then it is up to me to find a specialist. If I had an HMO she would give me a referral to who her office picked.

My primary doc moved to another job. I may just sign up with CVS to use them as primary for blood tests. I can read a blood test. If something is screwy I can handle it from there w/o a primary doc.

I guess I got lucky I've got a great PCP who doesn't hesitate to give referrals to specialists when needed. I'm on an HMO plan. I live in a populated area with lots of doctors who are in the network. I've had no problem obtaining care.

[Peter1469]

I guess I got lucky I've got a great PCP who doesn't hesitate to give referrals to specialists when needed. I'm on an HMO plan. I live in a populated area with lots of doctors who are in the network. I've had no problem obtaining care.

If I asked my primary care for a referral, she would give one. Then I would have to check to see if that doc is in network for me. But I don't need a referral.

[slideman]

If I asked my primary care for a referral, she would give one. Then I would have to check to see if that doc is in network for me. But I don't need a referral.

You're lucky I have a couple of conditions that need care. As you say I have to be sure the specialists are in the network; I haven't had any problems so far.
What I have lately learned is that the problem with Medicare advantage comes when you get really sick and the insurance company tries to withhold certain treatment modalities that are expensive. That situation is improving because people are complaining about it.