Navigating Specialist Referrals

Trying to figure out if you need to see a specialist for a particular problem or condition can be confusing.  While most insurance companies require patients to seek a primary care provider’s (PCP) referral to a specialist, some insurances are removing this restriction, allowing patients to choose their own specialists with some or little restrictions. However, many specialists will only accept referrals from another provider even if the insurance company does not require the PCP to refer.

Without a healthcare insider guiding the process, patients may not know what type of specialist to contact or what services they need to address a particular health issue.  This kind of self-referral can end up costing the patient time and money.  Without guidance, patients often go from doctor to doctor, incurring co-pays and other out-of-pocket costs while experiencing significant delays in diagnosis and treatment. 

If you find yourself wondering how referrals work, we are here to explain all you need to know including:

• Patient referral meaning
• Why referrals are beneficial
• When referrals are necessary
• The process of obtaining a referral: FMC provider and staff, the insurance company’s, and the specialists’ roles in the referral process

What is a Patient Referral?

Generally speaking, a patient referral is a communication from one healthcare professional to another, usually a specialist, requesting that they accept you as a patient to evaluate your condition, provide a diagnosis, and/or provide treatment or a treatment plan.

A referral serves several purposes:

• It ensures that the physician or healthcare provider is aware of the service requested and is prepared to provide it to you.
• It streamlines new patient paperwork as your medical history and other background information are usually provided with the referral.
• It makes patient intake, including processing insurance authorization matters, a smoother process for all involved.
• It informs your PCP of new conditions that you may have and any new medications you may be taking so that your PCP can provide you with appropriate, seamless care.

When are referrals necessary? Why do you need a referral to see a specialist?

Usually, referrals from doctors are recommended to ensure you receive the right care from the right health care specialist at the right time and provide a treatment plan for your condition.  The question, however, when are patient referrals needed will depend on your insurance policy terms.

Your FMC provider, also known as your primary care provider (PCP), is usually your first line of defense when it comes to your healthcare. Typically your FMC provider is the person you (should) go to first when you have a medical complaint or are seeking a check-up.  While PCPs are trained to take care of most routine health matters, they will sometimes determine that another specialized practitioner can best handle a particular issue.  In situations like this, they will refer you to a specialist. For instance, if you are experiencing ongoing foot pain, your FMC practitioner might refer you to a podiatrist or an orthopedist specializing in foot and ankle issues.

Usually your FMC practitioner will have a discussion with you about their preference to send you to a specialist if they feel it is necessary, but patients can also ask for a referral from their practitioner.  At FMC, we’ve worked with many specialists regionally and around the country and we will provide you with our recommendations of the specialists that we know and trust for our patients (rather than patients relying on word-of-mouth referrals from friends or Google reviews).  Often the referral will need to be in-network with your insurance company to pay for the visit, and we are usually aware of these restrictions and can help you find the perfect specialist for you and your insurance provider.

What is the process of patient referrals?

So how long does it take to get a referral from a doctor? And what is the process like?  Depending on your insurance provider’s requirements, the typical process for a FMC patient usually goes like this:

1. You have an appointment with your FMC provider where you discuss the need for a referral to a specialist. 
2. Your FMC provider will determine the type of specialist that will best meet your needs. Often this will be a specialist they’ve worked with before, likely have a relationship with. Your FMC provider will note the referral request in your medical records for that visit.  This request is immediately sent to a dedicated group of FMC staff working solely on obtaining patient referrals.  
3. Dedicated FMC referral staff will contact the patient insurance provider and obtain approval for the specialist visit, if required. You, as the patient, DO NOT have to reach out to your insurance.  Any requirements, restrictions, in-network confirmation, and other details from your insurance provider will be noted to the dedicated FMC referral staff and FMC will only proceed with the referral after the insurance company provides approval.  This process can be immediate (especially with electronic approvals), but others could take 3-4 days. 
4. Once insurance approval is obtained, the FMC referral staff will send a referral request form to the decided specialist.  This typically includes your relevant medical records, the reason for the referral, and where applicable, the parameters of treatment, and your Insurance and other demographics. For instance, you might be referred for eight weeks of physical therapy to manage shoulder pain.  
5. The referred specialist will review patient records, your FMC provider’s notes, insurance information, and will determine if they will accept the referral and make an appointment.  This approval process, and more importantly the appointment scheduling, on the specialists’ side, could take weeks to months depending on the specialists’ patient load, the season (Holidays/winter season tends to take longer), insurance requirements, and other variables.  At this time, we are seeing up to 9 months for a referral appointment with a neurologist; Rheumatologists and endocrinologists are also scheduling appointments 6 months out or longer.  However, some specialists appointments may be within 2-3 weeks from the request date.  The appointment date is provided by the specialist to FMC referral staff, who then contact you with the designated appointment time.  FMC has little to no ability to influence appointment dates, but we do try to indicate with the referral paperwork if we feel there is an immediate (stat, as it is referred to in medical terms), but the specialist ultimately makes the appointment date based on their availability and all the information provided. Any change of the date for the referral visit because of a conflict you have must be made by you with the specialist. It is important that you keep your appointment or inform the specialist of a change or cancellation. Otherwise, the specialist may not accept you as a patient next time.
6. After your visit for diagnosis, treatment, or therapy, the specialist will send a report to your FMC provider detailing the results of your visit, your diagnosis, and their recommendations, if any, for follow-up or further treatment.  This type of communication ensures that you have continuity of care.  At your next visit with your FMC provider, he/she will have all this information in their notes and will likely discuss the outcome of your specialist visits and any adjustments that need to be made going forward with medication, treatment, etc.  

Clear as mud, right?  Don’t worry, FMC will navigate the referral process for you.

Referrals are a complicated, sometimes lengthy process, but they can be necessary for quality of care for our patients.  Luckily for you, FMC providers and dedicated referral staff are here to take the burden away from our patients and help with the entirety of the process from the beginning to the end - from insurance approval, to scheduling the appointment, to ensuring communication flow between your PCP and specialist.