When we’re sick, we go see a doctor. According to numbers from the Centers for Disease Control, more than 4 out of 5 Americans saw a health care professional in the year 2015. In many cases, they probably saw a primary care physician. Primary care physicians have a wide range of expertise and can take care of everything from the flu to your annual checkup. But sometimes, patients need to see a specialist to receive more focused care.
Why referrals are necessary
Think of your primary care physician as an initial screener. You explain your problem, and he or she talks to you about it and examines you. Then, if necessary, your primary care doctor makes a referral to a specialist. For instance, if you’re having knee problems, you may be referred to an orthopedic surgeon. Patients who report having trouble hearing may be sent for audiological evaluations at The Hearing Group or a similar facility. Referrals are also important for insurance purposes, since your primary care doctor presumably already accepts your health insurance and can refer you to specialists that are considered in-network. Pre-authorization is also required in many cases, which means you or your doctor have to call your insurance company and get the OK to see a specialist before that specialist begins treatment.
It all sounds like it should be a fairly smooth process, but there are some complicating factors. One is the shortage of primary care physicians. The problem is worse in some parts of the country than others. There are several reasons for the shortage, including lower pay for doctors who are classified as generalists rather than specialists. In some cases patients can go to an urgent or express care facility if they can’t find a primary care physician. A patient with a sprained ankle can easily find walk-in medical services in the Staten Island area, because Staten Island is part of New York City, the biggest city in the country. But a patient in rural Oklahoma won’t have nearly as many choices, meaning they have to wait in line with dozens of other people at the only walk-in clinic in their small town. For those people, seeing a specialist could mean driving two or three hours to a major city.
Experts say complex financial incentives can also play a part in specialist referrals. If your doctor recommends you see a specialist and only provides one name, feel free to push pack a little, although make sure to be polite about it. Asking for a list of names rather than a single name can help you feel more in control of the process. Ideally, your doctor will be able to explain why a specialist makes sense for your specific case. If a doctor refers to a specialist as “great” or “awesome,” feel free to ask for a little more detail there as well. What have other patients said about the specialist? Have they been happy with their outcomes? You should be able to trust your doctor, and you should also be able to find out why your doctor trusts another doctor enough to send patients there.