Referrals, Pcps and health insurance?
March 11, 2018 11:07 PM   Subscribe

Can I ask my doctor for a referral to a doctor from a different hospital and other questions?

I've finally figured out how to get and use my health insurance ( Medicaid) but am still confused about some things.

I saw a doctor who works at a hospital. He gave he a referral to a neurologist at the same hospital and even made the appointment for me. However when I got home I saw the neurologist's reviews and they were horrible. Lots of people leaving one star reviews saying he was arrogant and superior. There's no way I want to see him and I'm canceling that appointment. So this time I want to look at reviews and ask my doctor for a referral to a specific neurologist I researched beforehand. My question is, is it not allowed, or at all rude to ask for a referral to someone at a different hospital than my doctor? Or should I only look for people at the same hospital (there aren't that many). Both in terms of insurance and what my doctor will find rude, I just want to know the general attitude to that because even though I only saw my doctor once I like him very much, so if I should apologize for asking for someone from a completely different hospital I will. For example, I know UIC accepts my insurance and I've been looking there, but will he think I'm saying UIC is a better hospital than his (which is much less well-known). Also, I was referred to a neurologist partially in order to get a sleep study. UIC has a sleep center with sleep specialists ( neurologists), is it ok to ask to go there?

Secondly I have a question solely about insurance. My insurance told me my doctor can't be my Pcp because he's not listed for that, but he's on contract and I can still see him. I kept asking what does that mean then, and the woman kept repeating the same thing. So if he's not my Pcp ( he can't be listed as my Pcp on my insurance card for example) how does is work differently? Will referrals made by him still be covered if he's not my Pcp? And do I have to get a Pcp? If so, do I have to go to my Pcp and tell them my basic health problems that I tell my other doctor to keep them informed?

I have an appointment tomorrow ( Monday) with someone who can be a Pcp that I made before I saw this other doctor. I am wondering if I should cancel that appointment or go. If I am allowed to go is there any reason to?

posted by anonymous to Health & Fitness (6 answers total)
Primary care doctor here. You can absolutely ask for a referral elsewhere. People do all the time because they've seen that specialist before or it's someone who specializes in a specific issue or because their mother-in-law's neighbor has recommended that doctor . I actually really like it when people have gone to the trouble of figuring out who they'd like to see because usually they've looked into whether that office accepts their insurance, etc.

At the hospital where I am employed we are encouraged to refer within the hospital system when possible, but not required. I will say that sometimes there are odd insurance issues--my local university hospital, for example, only takes Medicaid patients in their outpatient practices when they are referred by a doctor within their system (usually after a hospitalization) but hopefully that won't be an issue for you.
posted by The Elusive Architeuthis at 11:29 PM on March 11 [2 favorites]

Your doctor will not find it rude if you request a different referral. Even if he and the badly reviewed doctor are best friends, he'd find it very natural that you might have heard something from somebody or simply that you've heard something good about an altogether different doctor, if you have someone specific in mind. Be assured that you are fully empowered to pick--or veto, for whatever reason--your specialist. Also, if UIC, a teaching hospital, is in fact a better hospital, that's probably totally find with your doctor. Doctors sometimes work at hospitals for the name attached, usually in the case of academic institution (teaching hospital) v. not, but often that's unrelated. It's just a different job, being a clinical instructor, and a lot of people don't want to deal with it. The pay is often better at non-teaching institutions. It really depends--he's not likely to be offended by the implication. Or you could say that you WANT to be at a teaching hospital (UIC) because you like the energy, the contact with fresh, young doctors. Also academic institutions are highly coveted because patients often do fare better with layers and layers of oversight--interns and resident doing a lot of the legwork, attendings overseeing everything from afar except with tougher calls. (Conversely, med students and residents are by definition less experienced, so there's a clear downside there in encountering them first.) He might chuckle, but it really is a different vibe.

The insurance issue is less clear because usually insurance networks aren't hospital specific. They very often are, but not always. People can be in network but not be in the same hospital, although I don't think it's really possible to practice within a hospital but not be in same network as most of the doctors there. I think generally your PCP is the person who does all of the outgoing referrals if you have an HMO plan. If this doctor "can't" be your PCP, is it because he's not licensed in family medicine or internal medicine? Is he a specialist himself? Medicaid has its own rules, and it gets complicated, but I think the PCP is like the central hub: all things go through him or her.

One thing to note, though, is that online reviews are really hard to work with in the medical field, especially when it's just 1-2 bad reviews. Many people don't think of reviewing their doctors upon satisfactory treatment (quick--can you think of the site where you'd go if you want to leave a scathing medical review?), and those who are intent on leaving some kind of online mark have had wildly poor experiences, often with the healthcare system (their insurance, the hospital at which they had a procedure, accountants) and in ways that are only sort of related to the doctor himself. (It can be argued that the doctor in question is a legitimately bad administrator if it's always his staff that's getting chewed out online.) A far better way to get a sense of your doctor's reputation is by checking with the state board at which s/he's licensed. Keep in mind that some 70-80% of doctors (that's for most specialties; in high risk specialties like surgery it's like 100%) are eventually sued for malpractice and that often (70%) the cases are tossed down the line. You can also go to the county clerk to figure out all the litigation that a doctor has been involved in--just go wherever his practice is.
posted by flyingfork at 11:37 PM on March 11 [1 favorite]

1. Be sure that the doctor (or the health system he/she works for) you want to go see actually takes your state's Medicaid.

2. As mentioned above, please take online reviews for anything (but particularly medical ones) with the largest grain of salt you can find. I know everyone loves to look at Yelp/Google/whatever reviews, but are you really interested in putting your faith in random internet people who may have an axe to grind about anything and everything?
posted by kuanes at 4:13 AM on March 12

This is actually my day job (I'm an insurance/benefits counselor at a federally qualified health clinic), and I'd be happy to help out. I think you're here in Chicago based on the hospitals you're referring to?

Feel free to MeMail me a good way to contact you and I can email/call you.
posted by tivalasvegas at 11:01 AM on March 12

THe doctor at the hospital may have been a board certified hospitalist rather than internal or family medicine. Meaning they only coordinate care for patients in the hospital but do not follow patients, which is why you need a PCP (that is not a hospitalist).
posted by WeekendJen at 11:33 AM on March 12

Authorization/Referral person here.
1. YES - ask to be referred to another physician, you doctor will not mind, as long as the person you're being referred to is accepting new patients and accepts your insurance.
2. The physician you're seeing probably doesn't have a contract to be considered a primary care physician with your insurance. Likely, they have a subspeciality they're categorized as with your insurance. You will have to establish care with the new physician to obtain referrals for any other specialists you may need to see. It's not uncommon to have to do this with Medicaid plans.
posted by Sara_NOT_Sarah at 11:34 AM on March 12

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