Referral Madness
August 17, 2010 2:03 PM Subscribe
Chicken-and-egg medical referral problem here. I'm hoping someone who understands the mysterious world of health insurance and referrals can help out.
I need to make an appointment with a medical specialist. When I called them, they told me to contact my PCP for a referral and then call back to make the appointment. When I called my PCP's referral line, I was asked for an appointment date and was told they couldn't process the referral without one. So I called the specialist back and was told they couldn't give me an appointment date until the referral was processed.
Both of the receptionists I spoke to indicated that they deal with this exact problem all the time, and stated that the other party was wrong. In the end, the specialist told me to basically make up a date and use it to get the referral. I'll try that, but what gives? Who's right: the specialist or the PCP? How can it be that something as common and necessary as a medical referral is basically impossible to obtain?
I have gotten referrals a billion times in the past and never encountered this problem. If it matters, I live in MA.
I need to make an appointment with a medical specialist. When I called them, they told me to contact my PCP for a referral and then call back to make the appointment. When I called my PCP's referral line, I was asked for an appointment date and was told they couldn't process the referral without one. So I called the specialist back and was told they couldn't give me an appointment date until the referral was processed.
Both of the receptionists I spoke to indicated that they deal with this exact problem all the time, and stated that the other party was wrong. In the end, the specialist told me to basically make up a date and use it to get the referral. I'll try that, but what gives? Who's right: the specialist or the PCP? How can it be that something as common and necessary as a medical referral is basically impossible to obtain?
I have gotten referrals a billion times in the past and never encountered this problem. If it matters, I live in MA.
I generally have to make an appointment with my PCP before s/he will give me a referral, but having to have an appointment date with the specialist is, as you say, paradoxical.
Is there any way you can discuss this with your PCP? Maybe the staff that handles the referral line is misunderstanding some policy or another.
posted by muddgirl at 2:21 PM on August 17, 2010
Is there any way you can discuss this with your PCP? Maybe the staff that handles the referral line is misunderstanding some policy or another.
posted by muddgirl at 2:21 PM on August 17, 2010
You might also call the insurance company. The big guns might be calling the insurance company and having them conference in the doctor's office.
posted by chesty_a_arthur at 2:23 PM on August 17, 2010
posted by chesty_a_arthur at 2:23 PM on August 17, 2010
Response by poster: Bit of detail that I forgot: the girl at the PCP's office repeatedly referred to their computerized referral system and stated that, without the appointment date, they couldn't get to "the next screen" or whatever. Like, it was a physical impossibility to process the referral without a bit of data to plug into the "appointment date" slot. It just doesn't make any sense.
posted by tetralix at 2:23 PM on August 17, 2010
posted by tetralix at 2:23 PM on August 17, 2010
Is she 100% sure that the system wants the appointment date with the specialist. I would bet dollars on donuts that it wants to know the appointment date with the PCP.
posted by muddgirl at 2:27 PM on August 17, 2010 [1 favorite]
posted by muddgirl at 2:27 PM on August 17, 2010 [1 favorite]
It's a problem with the physician network. Yes, it's ridiculous, but your best bet is to just make up a date (might as well make it one you could actually live with) and give that to the PCP's office. Then, when you've been assured the referral is in the system, you can call the specialist's office to confirm an appointment time.
If you've got the energy, you could always write a letter to someone in the physician network (maybe they have a patient ombudsman?) describing the idiocy of the system. Really, the people who actually WORK there ought to be more proactive about getting this glitch fixed.
I used to work in the medical insurance business and even *I* have never heard of this one. Jeez...
posted by rhartong at 2:27 PM on August 17, 2010
If you've got the energy, you could always write a letter to someone in the physician network (maybe they have a patient ombudsman?) describing the idiocy of the system. Really, the people who actually WORK there ought to be more proactive about getting this glitch fixed.
I used to work in the medical insurance business and even *I* have never heard of this one. Jeez...
posted by rhartong at 2:27 PM on August 17, 2010
Contrary to everyone else's experience here, I have always had to give my PCP the date of the appointment with the specialist in order to get a referral, but the specialist has never cared about whether the referral was in the system at the time of the appointment. I just have to sign a waiver at the specialist's saying that if the referral doesn't go through I will be on the hook for charges. (I'm in MA too, FWIW.)
Maybe call your insurer and get their advice on the issue? I recently had to go through a hassle with Aetna due to a problem with the computerized referral system and the folks on the line were actually quite helpful.
posted by phoenixy at 2:37 PM on August 17, 2010
Maybe call your insurer and get their advice on the issue? I recently had to go through a hassle with Aetna due to a problem with the computerized referral system and the folks on the line were actually quite helpful.
posted by phoenixy at 2:37 PM on August 17, 2010
I am with phoenixy on this. I always have made the appointment first, then asked for the referral and the referral line is set up to ask for that information. I do my medical stuff in both MA and RI.
posted by chiefthe at 2:43 PM on August 17, 2010
posted by chiefthe at 2:43 PM on August 17, 2010
The whole point of the referral system is so that you will see your PCP before troubling a specialist, in case (a) your problem is simple enough for the PCP to deal with, or (b) you need to see a different kind of specialist than you (a non-doctor) would have expected. This has mostly been derailed by overworked PCP offices who will happily refer you to a specialist without seeing you first. Still, the idea that you would have to make an appointment with the specialist first before getting the referral goes beyond circumventing the system to making it actively backfire.
Two theories:
1) When I've worked with a referral person, they've needed to set up the appointment with the specialist for me. For that reason, they have asked what dates would work best for me, and then called me back once they figured out a date and time with the specialist's office. Could it be that this referral person is supposed to be making the appointment for you before/while trying to access the screen in question?
2) As Muddgirl said, the referral person may need the appointment date of when you saw your PCP and s/he approved the referral. Try asking her directly if she needs the date when you're supposed to see the specialist, or the date when you saw your PCP. She may not even realize that the other is a possibility (maybe new at her job?).
posted by vytae at 3:02 PM on August 17, 2010
Two theories:
1) When I've worked with a referral person, they've needed to set up the appointment with the specialist for me. For that reason, they have asked what dates would work best for me, and then called me back once they figured out a date and time with the specialist's office. Could it be that this referral person is supposed to be making the appointment for you before/while trying to access the screen in question?
2) As Muddgirl said, the referral person may need the appointment date of when you saw your PCP and s/he approved the referral. Try asking her directly if she needs the date when you're supposed to see the specialist, or the date when you saw your PCP. She may not even realize that the other is a possibility (maybe new at her job?).
posted by vytae at 3:02 PM on August 17, 2010
Your specialist might really want a referral meaning office notes / demographics. The insurance is another matter. In the office I used to work in, the insurance was your responsibility, but we needed background info before we could set any appointments.
However, assuming your insurance requires a referral, that referral is only good for a particular range of dates; it could be anywhere from 30 days /1 visit to 120 days / any number of visits. Get an idea from the specialist for approximately when the appointment would be, then go back to the PCP with a date in that range, and then get the referral. Your insurance might require knowing the actual date, which you can relatively easily change once it's set up, or it might not really care as long as it's within range.
posted by cobaltnine at 3:45 PM on August 17, 2010
However, assuming your insurance requires a referral, that referral is only good for a particular range of dates; it could be anywhere from 30 days /1 visit to 120 days / any number of visits. Get an idea from the specialist for approximately when the appointment would be, then go back to the PCP with a date in that range, and then get the referral. Your insurance might require knowing the actual date, which you can relatively easily change once it's set up, or it might not really care as long as it's within range.
posted by cobaltnine at 3:45 PM on August 17, 2010
This kind of thing also screams out for the intervention of a Health Advocate. I realize the OP did not say whether this insurance is employer provided, or whether their employer has a relationship with a Health Care Advocate. But in our home with adult kids we have a number of options for contacting an Advocate (since each of our employer plans offers assistance to the employee AND their immediate family). I have used my Advocate twice, and other members of my family have used their own or (when they were unemployed) each others. Just a thought for the OP or perhaps others who find this thread later.
posted by forthright at 7:04 PM on August 17, 2010
posted by forthright at 7:04 PM on August 17, 2010
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posted by grizzled at 2:14 PM on August 17, 2010