Referral Policy
We have, over the past several years, attempted to modify our referral process to meet the needs of our patients, their insurance carriers, and the various specialty care offices to which we refer. There are over one hundred specialists to whom we routinely refer, each of whom has their own office policies. Some of the physicians are particularly respectful of the referral process, judiciously use the referrals we authorize, and always reply with their findings in a timely fashion along with their reasons for needing further visits. Others deal exclusively with the patients, reply to the consultation very slowly, do not involve us in any further treatment planning or secondary referrals, and make all follow-up suggestions exclusively with the patients. This latter policy is unacceptable to us and will no longer be tolerated.
A referral to a specialist is a request for their help in determining how to address a specific problem; it is not a transfer of care. We do not expect one referral to a consultant to translate into our permission to treat the patient for life - without ever asking again if we, the primary care physician, still need the specialist's help. If we are not performing well enough in a specific area that you feel that you need repeated visits to a particular specialist even when we feel we can meet your child's needs here in our office, then you need to find a new primary care giver.
For each referral, you must contact our office at least one week before the referral appointment to give us enough time to review the request and contact you beforehand, if necessary. No referral will be authorized if it originates with a family's failure to contact us first to discuss the problem. No referral will be authorized if we are not given the one-week's lead-time.
Each insurance company has a different policy regarding referrals based on the products they sell you or your employers. In general, there are three major types of coverage: HMO coverage, PPO coverage, and general Indemnity coverage. The HMO coverage is the least expensive and has the tightest restrictions. It is marketed to the subscribers as allowing each patient access to the network wide group of physicians. Unfortunately for us, your physicians, we cannot be part of their primary care network unless we agree to accept part of the risk involved in care for you. In simple terms, if the cost of your medical care exceeds the budget the insurance company has set, the physician providers must make up the shortfall. We the physicians end up paying for your referrals. Each of us is ethically bound to provide the single best care we can provide for each patient we care for. We recognize this responsibility and take it very seriously; however, if we are responsible for each referral, we need to be part of each referral request. This may seem onerous and impractical to you, and it certainly is cumbersome for us, but it is absolutely necessary. We have contacted each of our specialist colleagues about this situation. They will require that you have a referral in hand before they provide specialty care.
For the other options offered by your insurance carrier, the referral restrictions may be less onerous. For a PPO product, you may not need a referral as long as the specialist is with your plan's specified network; for an Indemnity product you may not need a referral at all. It is ultimately your responsibility to determine the specific requirements and restrictions of your plan; as much as we can, we will help you with this responsibility, recognizing that there are a multitude of insurance carriers and products that we have to deal with.
