Health Insurance: Referral Question

Updated on October 13, 2012
S.G. asks from Fort Eustis, VA
18 answers

My health insurance doesn't require a referral to go to a specialist. Yet when I recently called one of the specialists in my plan, they informed me that they don't see patients without a referral. What? Can the office set whatever policy they want even if it's in direct contrast to the policy of one of the insurance plans they accept?
I loathe the health care system. There has got to be a better way!

What can I do next?

  • Add yourAnswer own comment
  • Ask your own question Add Question
  • Join the Mamapedia community Mamapedia
  • as inappropriate
  • this with your friends

Featured Answers


answers from Dallas on

I imagine that the doctor is requiring a referral as a way to safeguard against patients just walking in with something a practitioner could take care of, and wasting his time. Specialists typically have huge patient loads, and so they don't have time to filter through medical history and that kind of thing.

This isn't typical though, I've never had a specialist require a referral. Is there another one you can see?

I also loathe the healthcare system!!!!

2 moms found this helpful


answers from Washington DC on

This is that particular doctor's policy, not related to the health care system in general. I am guessing that he doesn't want anyone just walking in there for an appt wasting his time if they don't have an issue he can fix. It can get annoying if they don't tell you beforehand as I found out when I took my 5 yr old to the OT for an evaluation. I had pulled him out of school and had a 2 wk old strapped to me. Yeah, I wasn't leaving until they saw us, referral or not!

More Answers



answers from Fargo on

Actually, it's an excellent thing for a specialist to require a referral. The need for a referral eliminates people using specialists for things that an MD can handle. My husband has to book his endocrinology appointments a year in advance and we book our kids endo appointments 3 months in advance. Can you imagine what the wait would be if people bypassed their MD's and went to the endocrinologist every time they thought they had a symptom that required a specialist?

It's a great safeguard. It's easy to get a referral if you really need one. Just put a call in to your regular doctor.

6 moms found this helpful


answers from Chicago on

This isn't connected to insurance at all.

This actually prevents doctors who are specialists from seeing cases that could be handled at a lower level for much less money and many less tests. I see this as a way to REDUCE the costs of health care.
Now - I also believe in a capitalistic free society I get to see whomever I want whenever I want for whatever I want. And probably you CAN find that kind of specialist who is willing to take your money, when you could be seen by a General Practitioner or Internist much more cheaply to determine if it's something they can solve.

For example *most* Reproductive Endocrinologists won't see a woman who is TTC until they have been TTC for a year, are high risk or are over 40 (at which point it's after 6 months). This is because MOST of the time you want but don't *need* the bazillion dollars worth of tests that will determine there is nothing wrong with you, you are just impatient. Or that will tell you there is no reason for your 2 miscarriages... because there is no medical reason for your 2 miscarriages.

If the office has a policy get a referral from your regular doctor. If you don't have a regular doctor then you may need to look for a specialist in whatever specialty doesn't require one.... or establish a relationship with a General Practitioner within that system.

5 moms found this helpful


answers from Stationed Overseas on

Yes they can totally dictate their own office policy and like others have said this has nothing to do with insurance. I am super high risk when pregnant and I see a Maternal Fetal Medicine Specialist along with my regular OB. When I got pregnant a second time I was in contact with my MFM by email as I was out of the country. She said to call the office and make an appointment for when I came home. I called the office and the first question they asked was if I had a referral. Long story short I was able to make the appointment after the receptionist spoke with the doctor. The policy is in place so that someone who maybe really doesn't need a specialist won't take up their time. And I too have insurance that doesn't require a referral as long as you see a preferred doctor.

5 moms found this helpful


answers from Portland on

A referral is not a big deal. Just call your primary care doctor and ask for a referral. They will either call the specialist or send a note.

5 moms found this helpful


answers from Boston on

I agree they are not denying you access. They either want to know the background of the problem and any tests already done (a benefit to you to save time and money for unnecessary repetition), or they making sure the patient has already gone through the first round with a primary care physician before more expensive consultations are undertaken (again, a benefit to the patient as well as cost control), or are guarding against patients who "doctor-shop" to get more drugs without the various prescribing doctors knowing about the other prescriptions.

The absence of a referral requirement by your insurance company isn't necessarily a good thing, although it does allow a patient who already has seen a particular specialist to go back to that doctor without retracing steps with a primary care physician.

This should not be a hardship - your doctor's office probably has a person on staff who just handles referrals, and it's a formality. Just one phone call from you should do it.

5 moms found this helpful


answers from Charlotte on

Maybe they are screening their own patients this way, S.. Perhaps they are so busy that they want to make sure that another doctor agrees that they need to see the specialist so that they are only treating conditions that really have to do with their specialty...

I think that a doctor's office can set policy like this if they want to. Like charging you $25 or $35 in order to talk to a nurse, or a no-show fee. The insurance doesn't control all of their policies...

I'd just ask your doctor for the referral. Most doctors are happy to do that.


4 moms found this helpful


answers from New York on

Contrary to popular belief... insurance companies don't dictate private practice policy. So, yes, an office can elect to deny a patient without a referral. Think about it, your insurance doesn't require a referral so what happens if you go to a specialist and the insurance company then denies the request? You have to pay out-of-pocket. Most people cannot afford to do so. Then what happens? They either put you on a payment plan or eat part of the cost. Either way, the lack of referral could cost them money.

4 moms found this helpful


answers from Los Angeles on

My sister and BIL have a PPO that doesn't require referalls, yet some specialists have required one. It is their individual office's choice, as it was explained to my sister, and they do not work for the insurance companies. A referall is as simple as calling your primary physician to ask for one, who is then on the same page about your health care and can forward your records to the specialist who needs your medical history.

3 moms found this helpful


answers from Springfield on

Many specialists require referrals. I always thought it was because they're very busy and wanted to make sure you really needed to see a specialist, that it wasn't something your GP could take care of. It probably is also so they are guaranteed to get paid, but it could be to make sure their services are completely necessary.

Either way, getting a referral usually requires nothing more than a phone call to your GP. No biggy!

2 moms found this helpful


answers from Chicago on

Yes, the physician's office can set their own policies, because ultimately, they are the ones who are at risk of not being paid if the insurance company decides to question the validity of a claim. It is a CYA measure that physicians' offices have had to enact because increasingly the insurance companies give them the runaround and are rejecting or delaying payment on claims.

2 moms found this helpful


answers from New York on

Just like you can choose a doctor, a doctor can choose his patients. This has absolutely nothing to do with insurance.

2 moms found this helpful


answers from Dallas on

Yes Drs can require it. I am sure some drs have seen so many patiants that are just trying to get meds and they want to know they have gone through other avenues. Not saying that's what you are doing. I had a dr that used to work with my mom that did not even charge my insurance he saw me as a favor to my mom but since he was a specialist he required a referral from my dr. I just told my dr who to send it to. My dr had no problem with hit. They are so used to that type of stuff.

2 moms found this helpful


answers from Cumberland on

I couldn't get a mammogram without a referral from a doctor-no wonder women are suffering so much from breast cancer-with what we have to go through-and insurance says you can get an exam every year-what a hassle-waited 50 some years to get the first one and will never go back. Call your doctor-they will write you a referral that you can pick up and hand carry to the specialist. good luck-enjoy healthcare, such as it is, now, because if obamacare doesn't get repealed-this is the best and cheapest it will ever be.

1 mom found this helpful


answers from New York on

Depending on the type of specialist they may ask for a generic referral from your regular doctor saying what is being looked for. When I took my DD to a dermatologist for a questionable mole (which they didn't like and removed) they read the doctor's referral. If you're going for any kind of diagnostic work they'll also ask for the doctor's referral. But if they were asking for an insurance referral it could be the office staff being mis-informed. It happens all the time since there are so many different plans out there. Finally, some kinds of specialties will still need a referral with some insurance companies even if the plan doesn't have referrals for most specialists. Foor doctors and mental health providers are the common ones.

1 mom found this helpful


answers from Chicago on

Ask if they will take a letter from your doc. My insurance does not require referrals but sometimes doctors want paperwork say ing why the patient is coming to them. I remember about 2 yrs ago I had to take opne of my kids to a differenty doctor. They asked for a referral but when they looked it up, they saw no referral needed. But I did have a prescription sheet from my doc indicating why we were looking for the new docs appointment

1 mom found this helpful


answers from Norfolk on

Hi, S.:

Ask your family doctor for a referral.
Good luck.

For Updates and Special Promotions
Follow Us

Related Questions