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...