This information is provided by MetroWest Urology to help you understand insurance referrals.
What is an insurance referral?
An Insurance Referral is permission from your insurance company for you to see a specialist (anyone other than your Primary Care Provider, called your “PCP”).
But my doctor told me to see you!
We are very appreciative that our colleagues recognize the excellent care we provide (in fact, many are also our patients!), but unfortunately, recommending a patient see us is not good enough for insurance companies – they require a more formal process that documents the authorization.
Why do insurance companies require referrals?
Ostensibly to control costs. Plans like HMOs typically have lower premiums, co-pays, and deductibles.
How do I know if I need one?
Unless you have a PPO plan, you will likely need a referral. Plans that typically require referrals include (but are not limited to) HMO, EPO, and POS plans. The only way for you to know whether a referral is required is to contact your health insurance company – use the information for member services on the back of your card.
Who issues the referral?
The PCP assigned to you by your insurance company is the only person who can issue a valid referral. Please note, it is entirely possible for you to think one person is your PCP, and the insurance company to have another one listed for you. You should always check with your insurance company to ensure that the person you think is your PCP is actually listed as your PCP with them. Insurance companies are known to randomly assign PCPs without the patient’s knowledge. When you start a new plan, it is especially important to ensure your PCP information is correct.
Who is responsible for obtaining a referral?
You are. If you do not have one on file the day of your visit, you can either self-pay ($250 for new patients or $150 for established patients) or reschedule your visit to another day. If we submit a claim to the insurance company we have on file for you and they deny it due to lack of referral, you will be responsible for the cost of the visit. To protect yourself, confirm your insurance and PCP information each and every time you check in with us.
How do I get a referral?
In order for a PCP to issue a referral, you must have established care with that PCP. Generally, this means they will need to see you in the office for a “well visit.” PCPs may also require you to be seen at least once per year in order to issue referrals. Contact your PCP’s office – they generally have a person or department who handles the referrals. You may be asked to provide the following information:
- The date of your appointment – if you don’t have one officially scheduled with us, you can tell your PCP the desired date. Once your referral is in place, we will do our best to see you as close to that date as possible.
- Our tax ID: 82-3012603
- Our address: 67 Union Street, MOB Suite 308, Natick MA 01760
- Your doctor’s NPI number
- Ravi Kacker, MD = 1285807560
- If you usually see Stephanie Peña, PA-C, the referral will be under Dr. Kacker (MassHealth patients see below)
- Please ask for a referral that covers 12 months and at least six visits
How long does a referral last?
Typically, referrals are issued for 12 months, but your referral may be for a shorter period of time like six months, or even just one visit. Please discuss this with your PCP when you request a referral.
How does my PCP tell you a referral is in place?
Your PCP will send a fax with the details required for us to process a referral (start date, stop date, authorization number, number of visits).
How quickly can I get a referral?
That depends on your PCP office and potentially when you last were seen by your PCP.
What if it will be six months or more before a new PCP can see me?
A lot of PCPs have a limited number of “well visits” available and generally schedule out six months or more. Sometimes if you explain that you have a condition that requires a specialist, they will see you sooner for a “sick visit.” If you cannot wait the time required to see your PCP, contact your health insurance company. Sometimes they can facilitate a referral or switch you to a PCP who has more immediate appointments.
What if my PCP is part of the MetroWest Healthcare Alliance (MWHCA)?
For some health insurance plans, we do not need a referral if your PCP is affiliated with MWHCA. Please note, this refers to plans, not companies. For example, some BCBS plans waive referrals for MWHCA PCPs and other BCBS plans do not. Additionally, you may be told we are “in-network” with your plan – this does not mean the requirement for a referral will be waived. Here is a list of MWHCA PCPs – while we do our best to keep this list current, it is subject to change at any time.
What if I don’t like dealing with referrals?
We don’t like it either! If you get your insurance through your employer, let them know.
What else should I know?
It is your responsibility to immediately inform us of any changes to your health insurance or PCP. If you come into the office and say “Hey, I have new insurance” or “Oh yeah, I have a new PCP” we may not be able to provide services and/or you will need to self-pay.
My plan said I didn’t need a referral during COVID
Yeah, they told us that too, and then they denied claims for lack of referral.
A note for MassHealth patients
Unlike other insurance companies which let you see any provider in the practice, MassHealth plans that require referrals limit you to one MD only – this may result in a delay getting your appointment if the named provider doesn’t have immediate openings.