Why Do Referrals Take So Long?

An Explanation of the Referral Process

 

At Arroyo Vista Family Medicine, we often receive several questions from our patients about referrals and why the process takes so long.  The referral process is complex, requiring actions from a variety of entities. Because of this, it’s helpful to understand the considerations and steps that take place after your provider has referred you to a specialist.

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Insurance:

    

The first step we take is to contact your insurance company since each plan has its own unique set of conditions for referrals. This is one of many reasons we ask if there have been any updates or changes to either your address or your insurance every visit.  Once we have your insurance plan requirements, we can assess what authorizations, if any, are required to allow you to see the specialist. In addition, many insurance plans will only authorize consultations with contracted providers.

Submission:

    

After it has been determined that an authorization is required, one of our trained medical staff members will submit the appropriate forms and documentation to the insurance company. The insurance company will then process the paperwork and return a notification of either authorization or denial usually within 48-72 business hours. Once we receive the notification of authorization, we will then forward the referral and authorization to the specialist. Depending on the insurance company, this process can sometimes take up to 14 days.

Specialist Approval:

    

Specialists often have a process of their own, where they screen referrals for appropriateness clinically. They also must verify that they contract with the insurance company. After this process is complete, they will contact you, the patient, directly to make an appointment.

It is always in your best interest if we have your updated contact information in our electronic record system because that is the information we send to the referring provider. If you have had a recent change of address or phone number, it can delay the referral process. An easy way to check your contact information is to visit your portal account online or to call our office.

Even if you are one of the fortunate ones who has an insurance plan that does not require authorization for specialty care, many specialists will not accept a consult without complete records. These include visit notes, lab and x-ray results. In general, the longer you have had a problem and the more in-depth the workup is, then the longer it can take to collect the data the specialist requires. This is important because you want your appointment with a specialist to be as productive as possible and not repeat tests that have already been done.

It is not uncommon for a specialist to review the case and ask for further tests to be done prior to the consultation. Unfortunately, these very tests may require authorization from your insurer to perform.

 

Things Patients Can Do:

Tip #1: If you are able to schedule an appointment with the specialist we referred you to, it’s important to make

every effort to get to that appointment. Most specialists will not re-appoint you if you have a “no-show”. For those who do miss their appointment, the process above must be repeated, and often options for specialists are more limited the second time around, and require more travel for the patient.

 

Tip #2: If your provider has told you a referral will be made and you have not heard anything within at least two weeks, please call to check on the status of your referral. Because the process is complex, it can be subject to delays. Your patient care team can look into the referral for you and let you know where things stand.