General Question

LostInParadise's avatar

What is the purpose of a doctor referral?

Asked by LostInParadise (25653points) 1 week ago

About a year ago I had an eye exam at the local mall. I was told that I need to have cataracts removed. I made an appointment at one of the places that they listed and called my regular doctor to get a referral.

What assurance does the insurance company get from my doctor’s referral? Under what circumstances would my doctor not give a referral?

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5 Answers

josie's avatar

They have data that says that if your primary physician is maintained as a gatekeeper, it cuts down on utilization.
Less utilization, more money for the third party payer.

JLeslie's avatar

If your insurance requires a referral, it’s basically the primary doctor telling the insurance you need to see the more expensive doctor.

If the specialist requires a referral even though your insurance doesn’t, it’s the specialist wanting to make sure you are worth his time, and you really need his special services.

Darth_Algar's avatar

It’s to make sure that whatever’s going on isn’t a minor issue that your GP could handle.

gorillapaws's avatar

It’s to create a hoop to jump through. If you forget the referral (and they know x% does this) then the insurance doesn’t have to pay, then the insurance companies get to give themselves a nice bonus with the money they would otherwise be spending on the healthcare of their policyholders. Isn’t capitalism great?

JLeslie's avatar

And, what @gorillapaws said. Yeah, that too.

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