Will PCP possibly do referral on a condition that they have not treated?

Orthocoderpgu

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Salt Lake City, UT
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Have a Tricare patient. All of our providers are specialists and require a referral. Patient never gets evaluated by their PCP and comes to our office. Will PCP possibly do a retro auth when the PCP has not evaluated the patient for their condition?
 

SharonCollachi

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Clovis, CA
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If they did, I would say it would be fraudulent.

We do not accept self-referrals. The insurance companies we deal with do not require referrals, but our office does. We don't take self-referred patients. We want the PCP to evaluate their condition, treat it if it's within their knowledge to so do, then when it doesn't resolve itself, they can refer to us.
 

csperoni

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Selden
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I would say it is possible, but definitely not likely.
For example, our practice is an ob/gyn subspecialty of gynecologic oncology. Patients are typically sent to us by their primary ob/gyn. Some insurances ONLY allow an actual referral/auth from the PCP and not by the referring ob/gyn. If the ob/gyn already did a biopsy showing cancer or dysplasia, there is nothing the PCP can do to treat that patient. So I have personally had situations were a PCP will do a referral when they did not evaluate the condition, but will want the other physician records first.
But for 99.7% of other situations, the PCP will want to have seen (or telemedicine, or telephone or SOMETHING) with the patient.
 

pogiest

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I'm going to say no on both accounts.

I know Tricare does not back date authorizations. I say that because I used to have Tricare Prime and that's what I was told by Tricare. They will only do so in bonified emergency situations.

I'm 99.9% sure the PCP will not issue an authorization without seeing the patient first. I've been working in orthopedics for 9 years and yet to have a PCP issue an authorization for something they have not seen the patient for. My understanding is that most, if not all, insurance companies will want proof that the PCP has seen the patient first before they can request an authorization. If the PCP says no, the insurance will also say no.
 
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