Referral

[aaia2011]

Who is responsible for getting a referral? When they are new patient and when the patient is established? Does it matter if the patient was a consult or just new patient? We have recently had a denial due to lack of referral and we are not able to bill patient per denial. We where under the impression patient is responsible for getting the referral. Where we advised incorrectly?

 

[CodingKing]

It depends on your contract with the payer. If participating, its typically the providers responsibility to make sure there is a valid referral on file.

 

[heartyoga]

I have experienced this with AARP Medicare, Cigna Healthspring. We are a specialty office and we typically take patients only via referral. That way, we see them for their health issues that is specific to our specialty.

The denials due to lack of referral is because the above insurances want the referring provider to call in/ or get an authorization to refer to your provider. That way the insurances can control/limit which specialty patients get referred to and make sure they don't have to pay out of network, in case provider is not in network with them.

The way we work around it is ask the referring provider to retroactively refer you (on your date of service). This usually works for me.

Good luck!

 

[JCaillouet]

99.999% it is your responsibility for a referral. However:

1) You can have your front office staff do basic insurance verification and inform those who have the referral along the lines of:
"Hi! Your referral will expire before the next office visit! Pretty Please give your PCP a call?"

2) Speak with the Provider or Office Management to have a sign stating that it is the patient responsibility to update office staff for new insurance as well as if a new referral is needed. Attempt to get patient involvement in regards to the referrals.

3) Contemplate for those rare moments where the referral doesn't happen if you will do a 'patient liability' for no authorization. If you do so, be sure you document in advance.