Health network referrals are essentially a type of pre-approval procedure. Individuals who buy a health insurance policy must obtain a referral from their primary care physician before they can see a specialist (or any other physician working within that network). The type of referral required might depend on the insurance policy and the specific type of healthcare cover being provided.
Some insurance plans may require patients to have a written referral, obtained directly from the primary care physician. On the other hand, other types of health network referrals may be made through a simple phone call from your primary care provider to your insurance provider, with no need for any documentation.
The Importance of Health Network Referrals
Before you go to see a specialist for any health condition, you should always make sure that your insurance company has received the required referral from your doctor, whether in writing or verbally.
After you have checked with both parties, you can go ahead and make an appointment to see the specialist. In this way, you will be able to ensure that the visit to the office of the specialist will be covered by the health insurance plan and that you won’t have to pay for the treatment out-of-pocket. It will also help you and your doctor keep track of all your health management data in a systematic and comprehensible manner.
Many health maintenance organizations make it mandatory for members to select a primary care physician. This physician would then be responsible for the health management of the concerned individual in the foreseeable future. The physician would have to monitor all aspects of the person’s healthcare and will be a primary point of contact for all other healthcare professionals who diagnose or treat the person in any capacity.
The Role of the Primary Care Physician
As a result, if you have chosen such a primary care physician under a health maintenance organization, then your chosen doctor will be responsible for recommending treatment options, medications, specialist visits, etc.
The physician you have chosen will also have to provide all referrals for any required specialist visits or other services taking place within that network. As a result of these referrals, you will be able to see another healthcare provider or specialist within the network of your insurance policy, while having the costs covered by your insurer.
This information is extremely important for patients. This is because, if you do not have a referral from your chosen doctor or choose to see a specialist to whom you have not been referred, you may end up having to bear the entire cost of the treatment, or at least most of it.
This is because a specialist visit, made without the referral of your primary care physician, will not be covered by the health maintenance organization. Most such organizations only cover medical care obtained within the network, via referrals.
Reasons for the Popularity of Referrals
Over the years, health maintenance networks have become extremely common, especially in the realm of individual health insurance plans. This is because insurance providers are driven to control the spiraling cost of healthcare. They are therefore working to clamp down on the phenomena of persons seeking care outside of their own health network.
Moreover, a referral is also required for specialist visits in the case of point-of-service plans. However, some of the cost incurred through out-of-network treatment or healthcare is typically covered by most point-of-service plans, unlike health maintenance organization which only cover care obtained within the network through the referral system.
Even with a point-of-service plan, however, you will still need a referral from your primary care physician, but the referred specialist doesn’t necessarily have to be working within the network of the insurer.
Alternatives to Heath Network Referrals
Preferred provider organizations do offer health insurance plans which do not rely on health network referrals. However, because of the greater flexibility that they offer, they also have a tendency to be much more expensive than the plans offered by HMOs. Even when both the PPO and HMO plans offer the exact same benefits, the PPO will typically cost more than the HMO, which is why most people usually opt for the latter, despite the restrictions imposed.
Regardless of the type of health insurance plan you use, however, you will be responsible for paying the deductible for in-network services. If your plan uses coinsurance or copayments, then you may have to pay a certain amount for them too. You will usually not be covered by your insurer for any out-of-network medical care, unless it was obtained during an emergency.