Social Security & Medicare Questions: Does Medicare Require Me To Get A Referral?

Social Security & Medicare Questions: Does Medicare Require Me To Get A Referral?

Does Medicare Require Me To Get A Referral?

Q:  Does Medicare require me to get a referral?  I recently turned 65 and enrolled in a Medicare Advantage plan.  I'm unhappy with a specialist that I'm currently seeing who is spending only a few minutes with me when I visit.  He's ordered expensive tests and now a new prescription with no explanation of what the drug is or why I need it.  I did not fill the prescription when I learned my co-pay would cost more than $85 a month.  I would like to try another doctor. 


A:  Getting care from the right doctor is not only important to your health, but may also have a big impact on what you pay out-of-pocket for care.  But getting a referral is just half of the equation.   You will also need to check that the new physician is a preferred provider in your health plan network to get the benefits that come with your plan.

The type of Medicare plan you have will determine whether you need a referral from your primary care doctor before seeing a new specialist.  If your plan requires that you get a referral in order to be covered for that care, your primary care doctor will fill out a form or make a call and refer you.  Your referral can include routine lab work, tests, or X-rays.  Then check with your health plan to make sure the specialist is a participating provider.  If you fail to get a required referral prior to receiving medical services, then you may wind up with higher co-pays or worse, your plan may not pay for the services.

If your Medicare Advantage plan is a Health Maintenance Organization (HMO), in most cases you have to get a referral to see a specialist. First, you need to select a primary care physician who is in that plan's network.  Your primary care physician is responsible for managing and coordinating all of your healthcare.

If your plan is a Preferred Provider Organization (PPO) in most cases you don't have to get a referral to see a specialist, but doing so can help your primary care physician better coordinate your care.  To avoid paying higher co-pays or co-insurance, use your plan's network providers.  Your costs for covered services will usually be lower than if you use specialists who don't participate.

There may be situations where you may need to see a specialist and there isn't one in your plan's network, or within reasonable traveling distance.  If this is your case, contact your plan administrator to get permission to be evaluated by a physician who is not part of the plan network.  Ask for a letter of confirmation.

Call the customer service number of your Medicare Advantage plan to find out if you need a referral and how the procedure works in your plan.  If you have internet access, you can use your health plan's web site to learn what providers participate in your plan network, or call your plan to confirm their participation.