How well do you understand how your health plan works? According to a report in the March/April 2001 issue of the journal, "Health Affairs," less than 1/3 of the almost 11,000 people surveyed correctly answered four questions about the requirements of their plans. The question most often answered incorrectly asked consumers if they needed a referral before seeing a specialist. About 58% of those surveyed answered correctly.

Referral for specialty care

A specialist is any health care provider who is not a primary care provider. This includes cardiologists, eye doctors, surgeons, and other health care professionals who provide services for non-routine conditions.

Some managed care plans require the enrollee to receive a referral from the primary care provider or from the health plan before the enrollee obtains services from a specialist. Every plan has its own procedures and requirements, so it is important to know what your health plan requires for coverage. You will usually need to receive a written referral before seeing an out-of-network provider. If your health plan requires a referral from your primary provider before you see another network provider, you may also receive a written referral. However, some plans are using an electronic referral rather than a paper referral. The certificate booklet includes information on the procedures to follow and any notification requirements. If you have any questions, call your health plan before your appointment.

HMOs generally have the most restrictive referral requirements. Some HMO plans require enrollees to get a referral before obtaining services from any specialist, whether the specialist is an HMO network provider or an out-of-network provider. Other HMO plans will allow you to see any network provider without a referral. Most HMO plans require your referral request to be approved by the HMO before you receive any services from an out-of-network provider. In order to make sure your HMO will pay for the services of an out-of-network provider, you may want to contact the HMO before your appointment. Make notes of any phone conversation you have with the HMO staff so that you have a record of what you were told.

Preferred provider plans and point-of-service plans will allow you to see any provider for most services without getting a referral. However, if you obtain services from an out-of-network provider, you will have to pay a larger portion of the charges. Some of these plans do have referral procedures to allow you to receive the out-of-network services at a higher level of benefits. Your policy or certificate will explain what you need to do to receive the highest level of benefits.

There are exceptions to referral requirements. Managed care plans in Wisconsin are not allowed to require a referral for services from certain types of providers. You are not required to obtain a referral before receiving covered services from a network provider who specializes in obstetric or gynecologic services regardless of whether the network provider is your primary care provider. You are also not required to obtain a referral for chiropractic services from a network chiropractor.

When you do need to see a specialist, it is important to understand that you may not be able to choose the specialist, even if the specialist you wish to see is in your health plan's network of providers. If your primary care doctor practices in a clinic, you may be referred to a specialist in that clinic. If you are in an HMO, you will usually not be referred to an out-of-network specialist, even if that specialist is a nationally known expert in treating your condition, or if you had previously seen that specialist for treatment. Talk to your primary care doctor about any concerns you may have with your referral request.

Referrals are usually issued for a limited time period or for a limited number of visits. If you have a serious or chronic health condition, you may want a less restrictive referral to the specialist treating your condition. In this situation, either you or your primary care physician may request a standing referral to the specialist. The standing referral will allow you to see the specialist for a longer period of time or for more visits than the health plan's standard referral. You can also request that the specialist be allowed to provide you with routine health services. However, the plan may require your primary care provider to remain responsible for coordinating your care and may require you to obtain a referral from your primary care provider before you see any other specialist.

Conclusion

Understanding how your health plan works will help you make choices that will provide you with coverage for your health care needs. If you don't understand your health plan's restrictions, you may be responsible for expenses that your plan has denied because you did not follow the required procedures. And if you believe your health plan's procedures are more restrictive than they really are you may unnecessarily delay obtaining needed services. Read your certificate of coverage and other written material provided by your health plan. If you have any questions, call your health plan and ask.

If you need to see a specialist, ask whether or not you need a written referral. When you do get a referral, review it carefully. Most referrals have limits for the number of visits, the time period and the types of services that are being authorized. Be aware of those limits. If your health plan denies your referral request, you have the right to file an internal grievance with the plan. The grievance procedure is explained in your policy or certificate.

If you have any questions, or problems with your health plan, you can also contact the Office of the Commissioner of Insurance.

By Barbara Belling
Office of the Commissioner of Insurance