Why Do I Need a Referral?

Updated on May 12, 2009
M.N. asks from Chicago, IL
4 answers

I never understood why i need a referal from my doctor to go and see a specialist. i phoned my insurance and they said that I must. I just wanna go get my hearing checked out but I have to make a visit (and pay) my doctor before i can then get a referral - why is this? Is it just a money thing?

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answers from Chicago on

It's based upon the type of insurance you have. All policies are different. I don't know if you have different medical insurance types offered to you, but if you do -- you can investigate using a PPO or POS. In general, a PPO allows you to visit a specialist without a referral.

As for the money thing...I think it's a way your insurance company tries to save money by eliminating unnecessary trips to more expensive specialists. The insurance company prefers you are treated by your Primary Care Physician, with whom they have a pre-arranged reimbursement agreement.

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answers from Augusta on

You probably have an HMO. HMOs save money by using a "gatekeeper" your primary care provider. This person limits the costly use of specialists by being your first line treatment and controlling your access to specialty care. Your insurance company would rather have you pay more $$$ to see your PCP and be denied a referral then they pay more $$$ for you to see a specialist. Usually the PCP are under contract and receive bonuses for keeping costs low by limiting referrals and expensive procedures.



answers from Chicago on

thats just the way all HMO's work- if your able to next time just get a PPO. you can go to an ENT without a referral if you are willing to pay- often to just get your hearing checked you have to see the ENT after getting your hearing checked- if you get a referral you can just ask for just the hearing test without seeing the dr. good luck.



answers from Chicago on

You can call the doctor's office and see if they will give you a referral without making a visit. When I had HMO coverage, I was able to call the office and get a referral when it did not need an exam by my doctor. I would call and ask that the doctor call you back. The person on the phone may say you have to come in but if you ask for a call back, maybe not. With time pressures and such I know many doctors would rather give the referrals if an exam is not needed, giving them more time for patients that really need their care.

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