What's the point of a medical referral? (pain, surgery, advantage)

[buenos]

When I call a specialist, they say they can only take me is a PCP did a referral.
Usually healthcare professionals on the phone never tell me what they do and why. Even if I ask specifically they seem startled and try to further obfuscate.
At this point I have to make specific guesses, and maybe someone can tell if any are correct:
1. they are afraid that the insurance company would not pay them.
2. They like to serve their favorite PCP's patients only, or financially the network makes more money with in-network PCPs.
3. some kind of rule book rule
4. somehow it is related to ethics.
5. Legal liability
6. medical database not set up.

If it is 1. then the concern should go away if the patient wants to pay cash.
Of course they don't usually tell a patient "but you could pay cash and we can get on with it".
For some reason they shy away from mentioning cash. I wonder why? Would they be held liable for something if they mentioned cash to a patient? By who? Or they just assume, "son, you could not possibly have $2000"? A lot of secrecy and weird stuff in healthcare.

[suzy_q2010]

I suspect a doctor would be surprised that you even called without knowing ahead of time what that doctor does.

The referral requirement is usually due to limited appointment slots and not wanting them taken up for things that the PCP can handle. If you do have insurance, your plan may insist on it. You should confirm with your insurance before you call that the specialist accepts your insurance.

Some practices have a problem with self pay patients not paying even when they agreed to. The patient is given an appointment (having taken that slot), shows up, then asks to be able to pay "later", not at the time of the visit, or paying for followup visits becomes difficult.

#2 might cause some problems with legalities concerning referrals. The rest of your list, no.

[buenos]

Originally Posted by suzy_q2010

You should confirm with your insurance before you call that the specialist accepts your insurance. .

That is missing the point.
Can i get treated by a specialist without referral, if i pay cash? Are they willing to accept cash instead of insurance? If not, why not? How could it be the doctor's interest to involve insurance? Does insurance provide them with liability protections? What is the advantage for them, what is the value in it? people dont do things for no reason.

You were also implying that cash patients dont pay. With basic common sense you can get patients to provide the debit card 15 minutes before the procedure, so this problem does not exist.
Just because some guy had a certain behavior, it doesn't mean i will exhibit the same behavior, just because i am also some guy.

[atlguy44]

If you are on Traditional Medicare (not Advantage), it allows for self-referral to a Specialist as long as that specialist accepts Medicare. Plastic and cosmetic surgeons are happy to take cash and self pay since many of the procedures are not covered by insurance.

[Taz22]

If you are on Medicare and have an HMO, your PCP will have to refer you, it’s the way HMO’s are set up. People usually go with HMO’s because of the lower premiums or because they don’t mind having their PCP refer a specialist. A PPO generally has a higher premium, but is a good choice for people who like to choose their own providers. You can go in or out of network as you like with higher costs out of network. A PFFS, (private fee for service) works much like Medicare.

You don’t say what kind of plan you have, but if you like choosing your own provider, it’s worth your time to talk to an agent and discuss what your options are. You may end up saving money by changing your healthcare plan. If you’re taking prescriptions, be sure and have the agent check the cost of your drugs, and make sure they are covered under your plan. Co-pay and coverage can vary.

Of course you can pay out of pocket and see anyone, as long as you don’t use your insurance card.

[buenos]

I do have insurance, probably even a better kind. But all insurance introduces weeks or months of delays. My goal is to cut out the middlemen and get my 10 minute outpatient gastro surgery NOW.
Insurance companies do weeks of paperwork and prior approval documentation, and also introduce extra steps, while each step takes weeks and months. For example insurance insists for me to try the $30 cream first, and prove that i am still sick, and maybe after that they authorize the 10minute outpatient surgery.
Insurance is only useful for major medical, like a brain-surgery, in all other cases it causes more harm than good. Some people are trying to save me few thousand bucks against my will, but will not save me weeks of pain and suffering. That s the choice they would make for themselves, so they make it for me too. I didnt ask for that.

I am 3 months from first contact, but the thing is still not done yet, they constantly loose my paperwork, doctor out of town for weeks, orders unrelated tests according to "protocol", I just found out he is setting up this new practice and equipment on back-order and so on. I would switch, but only if the new doctor doesn't start from scratch, rather jump to the procedure on day one. Some magazine articles state they perform this particular surgery on first appointment. Can you imagine 3 months of pain and suffering for nothing? Sometimes switching doctors is necessary, but also becomes urgent and cannot redo weeks of consultation all over again. That is where cash could work, but I feel some resistance to that from some people.

[mike1003]

Originally Posted by buenos

That is missing the point.
Can i get treated by a specialist without referral, if i pay cash? Are they willing to accept cash instead of insurance? If not, why not? How could it be the doctor's interest to involve insurance? Does insurance provide them with liability protections? What is the advantage for them, what is the value in it? people dont do things for no reason.

You were also implying that cash patients dont pay. With basic common sense you can get patients to provide the debit card 15 minutes before the procedure, so this problem does not exist.
Just because some guy had a certain behavior, it doesn't mean i will exhibit the same behavior, just because i am also some guy.

It depends on the individual specialist! There is no hard and fast reason other than office policy


Some docs don't want to be bothered with hypochondriacs and those who diagnose with Dr Google


Some are just not taking new patients (common with some dermatologists)


Some large hospital groups require referrals

[reebo]

Originally Posted by buenos

I do have insurance, probably even a better kind. But all insurance introduces weeks or months of delays. My goal is to cut out the middlemen and get my 10 minute outpatient gastro surgery NOW.
Insurance companies do weeks of paperwork and prior approval documentation, and also introduce extra steps, while each step takes weeks and months. For example insurance insists for me to try the $30 cream first, and prove that i am still sick, and maybe after that they authorize the 10minute outpatient surgery.
Insurance is only useful for major medical, like a brain-surgery, in all other cases it causes more harm than good. Some people are trying to save me few thousand bucks against my will, but will not save me weeks of pain and suffering. That s the choice they would make for themselves, so they make it for me too. I didnt ask for that.

I am 3 months from first contact, but the thing is still not done yet, they constantly loose my paperwork, doctor out of town for weeks, orders unrelated tests according to "protocol", I just found out he is setting up this new practice and equipment on back-order and so on. I would switch, but only if the new doctor doesn't start from scratch, rather jump to the procedure on day one. Some magazine articles state they perform this particular surgery on first appointment. Can you imagine 3 months of pain and suffering for nothing? Sometimes switching doctors is necessary, but also becomes urgent and cannot redo weeks of consultation all over again. That is where cash could work, but I feel some resistance to that from some people.

Have you never used insurance before? There is no greater bureaucracy. This isn’t surprising.

There seems to be a confluence of issues for you - lost paperwork, a doctor’s vacation, a medical office that isn’t set up yet (!), customary foot dragging by an insurance company.

I’m sorry you’re in pain, but no one’s going to start cutting on you without dotting all the i’s no matter how much money you throw at them. Good luck

[Parnassia]

Originally Posted by reebo

Have you never used insurance before? There is no greater bureaucracy. This isn’t surprising.

There seems to be a confluence of issues for you - lost paperwork, a doctor’s vacation, a medical office that isn’t set up yet (!), customary foot dragging by an insurance company.

I’m sorry you’re in pain, but no one’s going to start cutting on you without dotting all the i’s no matter how much money you throw at them. Good luck

Instant gratification (as in "I've already diagnosed myself because you don't know what you're doing and I want what I want NOW! However, if I decide you screwed up I'll sue the pants off you.") isn't something the healthcare system is known for. There are some pretty good reasons for it.

[adjusterjack]

It's 5. Legal liability.


They aren't going to risk malpractice claims because they relied on a patient's self diagnosis without getting a referral and full history from the referring provider.