How to get Referrals through Hmos

Getting a referral to a specialist isn’t as hard as one may seem. Depending on the insurance company, it might be easier than expected.

As a referral corrodinator for a pediatrics practice, I do about 20 or so a day to all kinds of specialists. While most people seem to think that finding a provider that will be willing to refer out to a specialist they need to see is a daunting task, it’s actualy not that big of a deal.

First off, you have to talk to your insurance company to see which provider is "in network". This is as easy as calling the number on the back of your card. It may take 10 minutes to half an hour (depending on when you call), but this step will save you a large amount of headaches if you decide to bypass the referral process and go it on your own. Specialists ARE NOT cheap and you could find yourself with medical bills in the upwards of $500+ just for the single office visit, varying usually with how much lab work or diagnostic testing the patient must go through.

Generally speaking, companies like Harvard Pilgrim and Cigna tend to have very large networks and are commonly accepted most anywhere. Companies like BCBS (Anthem) tend to have smaller networks and to go outside the network may call for a clinical review.

After that is done, you should call your PCP (primary care physican) and talk to someone in the office about obtaining a referral. You most likely will talk to someone like me who does this as his or her primary job. Alot of times the referral will be able to completed without much more than this phone call, but there are times where the PCP is going to want to see the patient before sending them out to be seen by someone else. Be prepared to come in and discuss what’s going on. After the referral is approved by the doctor, the referral coordinator puts all appropriate information together and sends it to the specialist’s office.

As far as trying to understand the evil, twisted world of HMOs, the referral process is probably the easiest to master. Always remeber there is always someone there to help you out the best they can.