The short answer to this question is yes, but there could be complications depending on the health plan that you have. For instance, referral requirements are not always going to be required. Furthermore, the patient (you) will not always have to bear the costs of care covered by the insurance plan. In some health insurance programs, you can only see primary care physicians from that specific network, or else you won’t be treated.

For anybody actively looking for a viable health plan, it is recommended that you do research beforehand. Look up and choose the most viable option that will save you money in the long run.

What is a Referral and How Can I Get One?

In essence, a referral is usually a written request by your primary care physician that allows you to receive treatments from another medical professional. The referral doesn’t have to be written since some health plans do accept a simple call from the primary care provider tied to you.

In order to obtain a referral, you will need to visit the primary care physician assigned to you under your health plan. If you require specialized treatment beyond your PCP, then a referral will be made accordingly. This referral will determine the specific care needed to treat any respective illness.

With this in mind, it is important to note that referrals do have an expiration date. The average time a referral is valid for use with a specialist is 12 months after being issued. Alongside time constraints, the number of visits in which you’re allowed to see a specialist is limited as well. Nevertheless, in the case that you need to continue seeing a specialist but your referral expired or you ran out of visits, remember to talk with your PCP.

When Should You Get One?

A referral will be provided to you under certain circumstances by your primary care physician. These circumstances are determined based on whether you require further treatment, more clinical observation, or if an opinion by a more specialized medical practitioner is essential.

The services that a primary care physician will recommend might include various diagnostic imaging services (X-rays, CT Scan), pathology services (Urinalysis, Full Blood Examination), and – most importantly – a specialized doctor.

The Role of Health Insurance

There are a multitude of health insurance plans centered around giving you the best service possible. Now, the referral requirements and services offered will differ greatly amongst the types of health insurance plans. The main plans that we will be discussing are HMOs, PPOs, POSs, and EPOs. How each of these plans work and how coverage works in their networks will be discussed below, but we should keep in mind the fluctuation of costs in these plans.

Insurance Plans With Referral Requirement:

In a Health Maintenance Organization (HMO) plan, the cost of monthly premiums and cost-sharing will be much lower in contrast to those with fewer network restrictions. HMOs do require that patients choose a primary care physician that will be in charge of serving as the first point of contact for all healthcare needs.

Any recommendations for further treatment or the creation of a referral will be handled by the PCP. For any referral that is issued, you are only allowed to utilize it with the doctors or specialists within this specific health network. Unfortunately, if an individual opts to seek treatment outside of the network, or visit a PCP without a referral, then the HMO will not cover the costs of those treatments.

Comparatively, Point of Service (POS) plans function similarly to those of an HMO. However, in a POS plan, an individual does have the ability to access certain out-of-network services. Restrictions will be far lesser, although a PCP is required in order to cover the costs outside of the network.

Insurance Plans Without Referral Requirement

In contrast to the HMO and POS health plans, the PPO and EPO plans do not have referrals as requirements in their respective networks. Moreover, you are not required to pick a PCP in either of these plans.

For one thing, in a Preferred Provider Organization (PPO) plan the restrictions of who you can see outside of your provider networks are far lesser when compared to those of an HMO or POS. Insurers in a PPO plan prefer that you utilize certain providers within this network, but will still cover out-of-network costs. Despite some of these benefits, PPO plans tend to have costlier monthly premiums together with higher cost-sharing.

By the same token, Exclusive Provider Organization (EPO) plans tend to parallel the same services as a PPO plan. Instead, insurers offer an exclusive network of providers that you must solely utilize. With this plan, if you don’t use the listed providers, then the insurance plan will not pay for the costs under any circumstance. Basically, an out-of-network coverage is virtually nonexistent in comparison to a PPO service.

Think About Your Next Step

Acquiring a referral is not a difficult task in itself. For any individual that is seeking proper medical treatment and needs further testing or examination then they will generally receive a referral to see the right specialist. Whether you need to see a PCP or need a referral is entirely dependent on the health insurance plan that you have. By all means, you should do what is best for you and your own interests, but never forget to weigh the pros and cons of each provider network, and what will ultimately be more affordable for you.