Although a primary care doctor can help you navigate many of your healthcare needs, you may have medical conditions that require the care of a specialist. Understanding when a specialist should be consulted and whether or not your Medicare benefits provider requires a referral beforehand can help you streamline your access to care.
Determining When to See a Specialist
The function of a primary care physician is to help you establish health needs and then help you maintain common health goals and preventive care. An appointment with your primary care doctor is typically your first step in addressing any chronic or acute symptoms.
While they may offer an initial diagnosis or order certain tests to confirm or rule out any medical condition, they are not always trained or experienced to address more complex health needs. In those situations, your primary care doctor will refer you to a specialist.
According to the Association of American Medical Colleges (AAMC), there are over 120 specialty and subspecialty branches of medical practice. Their focus can be targeted on a disease or group of diseases, a specific organ or system of organs within the body. Depending on your medical needs, you may be referred to more than one specialist as a treatment plan is developed.
Original Medicare Referral Requirements
Original Medicare benefits through Part A, hospital insurance and Part B, medical insurance, do not need their primary care physician to provide a referral in order to see a specialist. Complications with coverage can occur if you see a specialist who is not Medicare-approved or opts out of accepting Medicare payments.
While some Medigap plans can help cover costs that occur from visits with these specialists, Medicare recipients should speak to any specialists beforehand to confirm whether or not they accept Medicare assignment.
Medicare Advantage Plan Referral Requirements
Medicare works with private insurers to offer Medicare recipients more choices for coverage. These Medicare Advantage plans must provide the same benefits as Original Medicare, but they often include additional benefits and have their own specific provider network. They also operate under different organizational categories.
- Health Maintenance Organization (HMO) Plans. The structural concept of HMO plans is care coordination, where your team of healthcare professionals work together to help you maintain your health needs. Because of this, your plan may need your physician’s referral for specialists, and the specialist must be an in-network provider when seen for non-emergency needs.
- Preferred Provider Organization (PPO) Plans. This plan offers coverage for both in and out-of-network providers, but your out-of-pocket expenses will typically be lower if you see in-network specialists. Referrals are rarely needed for most circumstances.
- Private Fee-for-Service (PFFS) Plans. Referrals are not usually necessary with this type of plan, but you should check with the specialist to confirm they accept this type of coverage and the fee schedule it sets.
- Special Needs Plans (SNPs). Some common yearly screenings and exams performed by specialists may not require a referral, but most do. As with other plans, non-emergency specialists must be in-network providers in order to qualify for coverage.
Each insurer can have policies that differ from these general guidelines, so it may be necessary to consult with a representative for your specific plan to verify their policy with regard to specialist referrals.