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sneakinsnake t1_iu34p98 wrote

Reply to comment by UltimateZo in Boston Healthcare System Total Garbage? by UltimateZo

Your original statement that a referral is necessary to see a specialist in Boston is simply untrue. I'm not sure where you heard that from.

I'm assuming your insurance plan requires a referral from your PCP to see a specialist or the specialist you are trying to see requires a referral. In either case, go find a PCP that can see you in the next day or two to get a referral. It doesn't matter who the PCP is - find anyone who looks decent and can see you as soon as possible.

https://www.zocdoc.com/search?address=Boston%2C%20MA&city=Boston&insurance_carrier=-1&insurance_plan=-1&state=MA

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UltimateZo OP t1_iu35746 wrote

I promise you my PPO plan requires NOTHING from me to schedule with anyone anywhere in the country. If you call the scheduling office for any of the specialty departments they will ask for your referral. Or they will ask for your medical ID and lookup if you have a referral in the system to their department. They will REFUSE to schedule without that referral, regardless of insurance.

This was the case for both Neurology and Endocrinology. Maybe my blanket statement of “specialist” is too broad, but I assume Many many more specialty areas require the same.

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sneakinsnake t1_iu35o7e wrote

Sure, so then the specialist(s) you called require a referral to been seen sooner or at all. In that case, go see any PCP.

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Particular_Ad_7831 t1_iu3kkfg wrote

Your PPO probably requires a prescription for a specialist, not a referral. An insurance referral is for HMO plans. PPOs can require an order.

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Wilmamankiller2 t1_iu5pcap wrote

No. Many specialists now require a “referral” (not an insurance referral) from another physician which they then evaluate to see whether they will see you or not. It depends on many factors but if they dont feel that the referral is appropriate or they dont want to deal with your issue that can refuse to see you. Again it has zero to do with insurance. There are many more patients than drs available to see them which is why there are such long wait times.

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sneakinsnake t1_iu5qu3w wrote

>Many specialists now require a “referral”

Correct, but not all require a referral.

Also, it MAY also have to do with insurance depending on your plan. Saying it has zero to do with insurance isn't accurate.

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Wilmamankiller2 t1_iu5ryml wrote

As I just explained, the referral required has nothing to do with insurance. It is a completely separate process. Source- work in medicine at a major Boston hospital

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sneakinsnake t1_iu5y3st wrote

"Many HMOs require that referrals be approved prior to any scheduled appointment with a specialist. " - https://www.bidmc.org/centers-and-departments/general-medicine-primary-care/healthcare-associates-hca/insurance-and-managed-care-guidelines

"If you have a health maintenance organization (HMO) or point of service (POS) plan, you'll probably need to go to your primary care physician (PCP) first. If they agree that you need to see a specialist, they'll refer you to one and make note of it in your medical file. Some health plans require that the referral be made in writing while others accept a phone call." - https://www.verywellhealth.com/what-is-a-referral-health-insurance-1738605

"Some health plans require referrals or prior authorization before you receive services from health care providers other than your primary care provider (PCP)." - https://content.naic.org/article/consumer-insight-understanding-health-insurance-referrals-and-prior-authorizations

"A few services require both a referral from your PCP and prior authorization from The Health Plan. This means that your PCP has to OK the service and get an OK from The Health Plan, too." - https://www.healthplan.org/for-you-and-family/tools-resources/referrals-prior-authorizations

"The term Insurance Referral refers to the permission or authorization of your insurance plan that they may require in order to see a recommended specialist, doctor, hospital, or type of treatment." - https://www.scarsdalemedical.com/patient-information/patient-forms/referrals-patient-resource.pdf

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You're right, though. Referrals have zero to do with insurance plans. 🤔

The OP had originally made the claim of "A referral is necessary to see a specialist in Boston regardless of your insurance" which isn't true in the sense that there are no Boston-specific regulations around this that I'm aware of. All I'm stating is that some insurance plans like HMOs may require a referral from your PCP before you're able to see a specialist. What's also true is that some specialists require referrals to be seen sooner or at all regardless of your insurance plan (which is what I think you're trying to say?).

Either way, if the OP has an insurance plan that requires a referral, they should get one. If their plan does not require a referral, seeing a PCP first may expedite the process in seeing a specialist sooner rather than later.

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