Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services.

♦ In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor.

If you don’t get a referral first, the plan may not pay for the services.

• Primary care doctors are in effect gatekeepers for HMO plans.

Many people complain this is a way to ration care. The practice can save the plan money.

♦ Unfortunately, referrals tend to be to doctors and testing facilities financially tied to the organization the primary care doctor works for.

There are anti-kickback laws in place that prohibit doctors from paying for referrals.

However, the Affordable Care Act (ACA) does include allowances for keeping referrals in the same network.

Some experts even believe that the ACA diluted the anti-kickback provisions already in place.

The thought behind the language in the law was to reduce costs, but doctors whose practices are owned by hospitals may receive a fee-for-service payment for keeping referrals internal.

♦ A word of caution - it is your responsibility to make sure the doctor or facility you are referred to is in your plan's network.