How Do Doctor Referrals Work? Plus, How to Find the Best Specialist for You

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So your doctor just referred you to a specialist, but you have no idea if this specialist is the right fit for you. Or, maybe there’s a physician you really want to see, but their office is requiring you to submit a referral first. 

What’s the deal? You might be wondering why doctor referrals are even necessary. Shouldn’t you be able to see whoever you want for your health care? And how do you decide who you want to see, anyway? Should you ask friends and Google for doctor reviews?

Let’s put your burning questions to rest. Below, we’ll explain how doctor referrals work and the best way to determine whether the specialist you’ve been referred to is the right one for you. (Spoiler alert: It has nothing to do with reading online reviews from strangers.)

What Is a Doctor Referral?

A doctor referral is more than just a word-of-mouth recommendation or suggestion. According to Healthcare.gov, it’s “a written order from your primary care doctor for you to see a specialist or get certain medical services.” 

The doctor referral system was created to streamline the process by which one doctor communicates with another doctor about a patient’s unique needs. As researchers explain in this article published in The Milbank Quarterly, ideally, a referral creates a relationship between the referring provider and the specialist that allows them to collaborate on the best care for the patient, with information flowing both ways between PCP and specialist.

Imperfect as it may be, referrals are still heavily relied upon. In late 2021, MediFind and Rare Patient Voice surveyed more than 1,000 patients living with a wide range of rare health conditions. Through our research, we found that, even with the plethora of online resources available at our fingertips in this day and age, doctor referrals are still the number one path to finding a skilled specialist. Nearly half (45%) of our respondents got their correct diagnosis from a provider they found through a doctor referral. 

What Does It Mean When a Doctor Gives You a Referral?

It usually means that the condition or symptoms you’re presenting with are outside of their expertise or require procedures the referring physician is unable to provide. Doctors write referrals when they think a specialist has better knowledge that can help you with a diagnosis and/or treatment or when the specialist has the equipment and skills to run tests and provide procedures.

For instance, your family doctor might have the knowledge to ascertain that your irregular mole might be cancerous, but they might then refer you to a dermatologist to biopsy the mole and remove it if necessary.

Why Are Doctor Referrals Important?

Often, they’re required.

By your health insurance 

Your insurance company might require a referral before it will cover a visit to a specialist. It depends on your health plan, so be sure to check.

  • If you have an HMO (health maintenance organization) plan, a specialist visit requires a referral if you want coverage for it.

    HMOs typically have a lower premium, but that perk comes with its own price: you’re limited to physicians who are in-network, and if you want to see a specialist, you must see your PCP first and get a referral.

    That means if you were experiencing heartburn and thought you needed to see a gastroenterologist, if you have an HMO, you would have to schedule an appointment to see your PCP first. Then, the PCP would write a referral to a GI specialist if they determined that was the next best step for you.
  • If you have a PPO (preferred provider organization) plan or EPO (exclusive provider organization), a specialist visit does not require a referral.

    As insurance company Cigna explains, a PPO gives you more options, providing coverage for care you receive, whether in-network or out-of-network (though in-network care will come at a lower cost to you). An EPO, like an HMO, will only provide out-of-network coverage for medical emergencies. But unlike an HMO, an EPO does not require a referral for specialist visits.

Of course, regardless of the type of health plan you have, be sure to check your benefits to know how much your insurance is going to pay for that visit or procedure. You might still owe a copay or need to meet a deductible, for example.

By the practice or hospital system

Some specialists require a referral before you can schedule an appointment with them—regardless of your insurance. Because doctors, and particularly specialists, have an increasingly large number of patients to see, this is often a gatekeeping tool to prevent them from seeing patients who don’t truly need their expertise. 

As Kaiser Permanente explains on its website: “Sometimes you may be asked to check with your primary care doctor first, even if your health plan does not require a referral. That’s because in certain specialties and sub-specialties, appointments slots are kept for patients with urgent needs.”

Your referring doctor likely has expertise that Google doesn’t

Even if it’s not required, getting a referral from your PCP might be wise to do anyway. That’s because your doctor, through networking and feedback from patients, will have more insight into a specialist’s particular areas of expertise than a Google search can reveal. Your PCP also knows the details of your case the most intimately of anyone else you could consult.

While patients commonly check Yelp and Google reviews to decide if they should see a particular specialist, the truth is those reviews are from people who don’t share your unique condition and situation. Further, a lot of those reviews are on the attitude of the front desk staff or the bedside manner of the physician. And when you’ve got a serious or rare disease, clinical expertise about your specific condition is likely most important to you. Various studies have concluded online reviews do not reliably indicate the quality of care provided by a physician, so take those ratings with a grain of salt.

That’s exactly why MediFind was created. We’re the only resource that continuously evaluates the expertise of doctors in each health condition, giving you more objective results than Google or Yelp.

Find a doctor

Doctor referrals factor into how quickly and accurately you get diagnosed and treated

Lastly, referrals help ensure you don’t waste your time seeing a specialist you didn’t really need to see. Ultimately, this will help lead to a faster diagnosis and treatment.

So, How Does a Doctor Decide Who to Refer You to?

Clinical expertise

Another finding from our study is that clinical expertise is the single biggest factor both patients and doctors take into consideration when pursuing a referral. The only problem? There’s no formal way to assess the clinical expertise of another doctor, especially if they don’t know them well. This is through no fault of their own, as they’re often limited to specialists they’re familiar with, such as those they know from medical school, conferences, or those who work within their same practice or hospital system.

Many providers use MediFind to overcome this challenge. They search for specialists with expertise in specific health conditions to ensure these doctors have the clinical expertise necessary for providing the best care for their patient.

clinical expertise drives specialist choice

Hospital system

Some physicians feel pressured by their employer to refer to doctors within their own hospital system. Businesses, of course, need money to keep running. By referring within their system, they keep that money within the system, too. 

In 2018, Kyruus and Wakefield Research surveyed 200 physicians in the U.S., and 84% of doctors said their health system had “requirements around referring to in-network providers.” But, perhaps this will restore your faith: A 2018 Medscape survey found that 86% of physicians would go against their health system’s pressure and refer outside the system, including if it meant the patient would get the best treatment or if it was the patient’s choice.

Even if their employer does not pressure them, however, some providers might simply feel more comfortable referring within their system due to sheer familiarity with doctors there, along with the added benefit of speed: patient medical records are already in the system, making them more readily accessible and avoiding delays that can result from the record transfer process.

Familiarity

Often, doctors write referrals to specialists because they’re colleagues they know from medical school, residency, or professional societies, or because they’ve worked with them before. In fact, specialists sometimes call doctors and introduce themselves, encouraging them to make referrals to them. The referral system, after all, is a way for specialists to boost business at their own practices. 

There’s even an entire industry that has sprung up because of this. Physician liaisons and referral consultants sell their services to doctors who want help increasing referrals to their practice.

Marketing is a part of any business. But as a patient, you deserve to know the factors that might be influencing the decisions of your care providers.

Other factors

In research published in Annals of Family Medicine, Dr. Kraig Kinchen and colleagues found that primary care doctors also take into account factors such as previous experience with the specialist, appointment timeliness, and the quality of communication with the specialist.

Do Doctors Make Money From Referrals?

Many of us are aware that businesses commonly create affiliate marketing or referral programs that pay commissions to individuals who send customers their way. Does the same thing happen when a doctor writes a referral to another doctor? 

There are laws limiting or prohibiting financial incentives for referring providers, including the Anti-Kickback Statute, of which the U.S. Department of Health and Human Services Office of Inspector General writes: “In some industries, it is acceptable to reward those who refer business to you. However, in the Federal health care programs, paying for referrals is a crime.”

Beyond law, it’s a matter of ethics, too. The American Medical Association calls such behavior “fee splitting” and deems it unethical.

Can I Request a Referral to a Specific Specialist?

Yes, of course. This is all a part of patient autonomy. You have a right to ask that your doctor write a referral to a specialist or even to request that they refer you to a specific specialist that you’ve decided is the right one for you. 

How Long Does the Referral Last?

Doctor referrals expire! Although the length of time varies by insurance provider and plan, referrals do have a shelf life. So don’t wait too long to get that appointment scheduled. Blue Cross Blue Shield of Michigan, for example, says that referrals last anywhere from 90 days to one year.

What Happens If You See a Specialist Without a Referral?

If your insurance requires a referral, but the specialist’s office does not, and you go to see the specialist—you could find yourself facing a medical bill you can’t pay. Again, this is because some insurance plans, such as an HMO, will not cover the cost of a specialist visit that has not been authorized with a referral. In a case like this, though, you can ask for the cash price of the visit before you arrive so you’re not surprised with a huge bill later. It’s also worth mentioning that, often, if a doctor’s office knows your insurance won’t cover the cost of the visit, they’ll require that you pay upon check-in before the doctor will even see you.

If your insurance does not require a referral, and you go to see a specialist without a referral, you might waste time seeing someone you didn’t actually need to see. This hearkens back to what we mentioned earlier about clinical expertise. Your primary care doctor went through medical school and extensive training for their profession, so they are able to provide an informed opinion on your care. Here’s an example: While a patient might think that their skin condition requires a visit to a dermatologist, their PCP, upon examination, might conclude that it’s a symptom of Sjögren’s Syndrome, an autoimmune disease in which a rheumatologist would specialize.

How Do I Know the Doctor I’ve Been Referred to Is Any Good?

Unfortunately, it hasn’t always been easy for patients to accurately deduce the answer to this. In an effort to find the best doctor for their unique health needs, most people resort to asking their friends and family, posting to social media, or reading online reviews. But the issue is that these sources do not have intimate knowledge of your specific condition, nor do they have the formal education or training required to make such an important decision for your health care.

Think about it: Leona might ask her Uncle Rafael for a rheumatologist recommendation, and Uncle Rafael might rave about Dr. Smith, whom he sees for his rheumatoid arthritis. But what gets missed in this interaction is that Dr. Smith is an expert in arthritis, and what Leona has is Behçet disease, a rare condition that causes widespread inflammation of the blood vessels, in which Dr. Smith has limited or no experience.

For a decision this important, it’s wiser to use a platform like MediFind, where you can find doctors not just by specialty (e.g., rheumatology) but also those with expertise in your specific condition (e.g., Behçet disease). So while Dr. Smith might be an excellent Rheum for Uncle Rafael because he has advanced knowledge about arthritis, by using MediFind, Leona can get the best care for her by connecting with a specialist in her area who has advanced knowledge of Behçet disease.

MediFind Find a Doctor

If you’ve received a referral to a specialist, and you want to check if that specialist is an expert in your condition, look them up on MediFind.You can type in a doctor’s name and see their level of expertise in specific conditions, along with all the necessary information (such as the provider’s accepted insurance plans and contact information) to make an informed decision. You can also look up top doctors by condition.

Second Opinion

If you’ve already seen the specialist you were referred to and weren’t satisfied, type their name into our Second Opinion search. MediFind will show you other specialists with expertise in the same area but who are not within the same network as the original specialist, providing you another option for care.

Navigating Doctor Referrals Doesn’t Have to be So Frustrating

We get it. Doctor referrals are a mystery to many and can feel like an unnecessary barrier to care. We hope that, after reading this article, you understand why the referral system is in place and how to navigate it skillfully as you seek a diagnosis or treatment for your condition.

MediFind exists to help you find better care, faster. And that includes helping you quickly determine if the specialist you’ve been referred to truly possesses the clinical expertise for your condition. 

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