Do I Need a Referral to See a Doctor or Specialist?

Some specialists require referrals while others allow all patients to book appointments. Try our online primary care doctors and specialists.

06


Feb

Do I Need a Referral to See a Doctor or Specialist?

General practitioners generally do not require referrals.

If you want to see a new primary care physician, you should be able to easily make an appointment over the phone—and in some cases, online—without needing a referral. The vast majority of general practitioners do not require a referral from another physician in order to see a new patient. The limiting factor is generally the patient’s health insurance plan (or lack thereof), and in some cases the doctor’s availability or a geographical limitation. If you have a non-emergency situation for which you believe that you need to see a specialist, the recommended first step is to speak with your primary care physician.

As of 2019, the United States has 156.7 primary care physicians per 100,000 people, with Rhode Island having the highest concentration of primary care physicians at 264.5 and Idaho the lowest at 95.7. According to a Kaiser Family Foundation report, the U.S. has 260 physicians per capita (including specialists). This proportion of physicians is comparable to Japan (240), Canada (270), and the U.K. (280) but far below some western European countries such as Austria (520), Germany (430), Italy (400), and Spain (390).

Primary care physicians are qualified to diagnose many conditions which they may not be qualified to treat, and some primary care physicians have a secondary specialty. Your primary care physician can refer you to a specialist who is qualified to treat your issue. For example, if you have a broken bone you may need a referral to an orthopedic surgeon whose specialty is treating issues with the bones and joints. While your family doctor can administer an electrocardiogram test to check for signs of heart disease, you will need to see a cardiologist to actually receive treatment for most heart conditions. In an emergency situation such as when suffering imminent heart failure, you might be able to bypass the referral process or get an immediate referral to a cardiologist from an emergency room physician. Also, even for non-emergency situations, each medical group or clinic may set its own policies on referrals and some choose not to require referrals: for example, University of Utah Health advertises that “you don’t need a referral to schedule an appointment with one of our cardiologists.”

 

Why do some doctors require referrals?

There are a few reasons why most medical specialists typically will not see a patient without a referral from a general practitioner. The foremost reason for requiring referrals is to keep health insurance costs low. Most health insurance plans do not like to cover costs for expensive visits with specialists unless they are absolutely necessary. Even then, different health plans may either cover completely, cover partially, or decline to cover certain types of specialty care. A primary care physician uses his or her discretion to act as a “gatekeeper” against unnecessary referrals, which helps keep the health insurance plan’s costs as low as possible.

The second most important reason for medical specialists to require referrals is that these doctors’ time is not unlimited. These specialists must focus their limited time and resources on helping patients with the most severe immediate needs and the correct diagnoses. For example, if a patient attempts to self-diagnose using the internet and schedules an appointment with a cardiologist because of chest pain, chances are that the patient may not have a serious heart problem and may have simply panicked. The cardiologist may end up dedicating his or her limited time on what is ultimately a false alarm while other patients with serious heart conditions have to wait longer to receive care. Exceptions may be made in case of emergency, but as a general rule you cannot simply call a cardiologist’s office to schedule an appointment.

 

Exactly which types of specialists require referrals?

There is no easy answer to this question, as it varies widely depending on your health insurance plan. Some insurance plans cover only one visit of a particular type per year, or only a certain percentage or amount of the visit cost. Many plans will cover specialty medical visits but only if they are in-network referrals. If you see a doctor who is out-of-network, you may need to pay a larger co-pay or the entire cost out-of-pocket. Often, you will still have a co-pay for any specialty visit, even if your insurance plan includes some coverage for them. Whatever is not covered by your insurance plan directly will need to be paid out-of-pocket as a co-pay. You will need to check with your health insurance provider to find out exactly what is covered and what is not.

 

What specialists can I see without a referral if I am uninsured?

If you have no health insurance whatsoever, then some specialists will be willing to see you if you explain your situation. As there is no standardized healthcare system in the U.S., the policies for screening of patients are left up to the individual providers. If one specialist will not see you without a referral, another probably will. You will need to call the office of the individual doctor whom you wish to see and ask first, whether they are accepting new patients; and second, whether they accept self-pay patients without referrals. You may still find that seeing a primary care doctor first is more affordable, although it may be a longer process. If you are looking for a quick and easy assessment, try using SAMI-Aid’s online doctor service to speak with a doctor online or over the phone from home. If you are considering paying out-of-pocket to see a cardiologist or other costly specialist without insurance, you may wish to do your due diligence in researching and comparing prices and options for financial healthcare assistance as specialist visit expenses can be much greater than for a primary care physician.

 

How can SAMI-Aid help me see a doctor quickly?

With COVID-19 still a concern, seeing a primary care physician in-person may be challenging. Having a backup plan for accessing healthcare is strongly recommended. Telehealth services such as SAMI-Aid provide the perfect buffer zone for your healthcare during this unprecedented upcoming flu season. If you are looking for a specialist doctor near you now, SAMI-Aid offers a premium feature for finding and comparing local doctors—both primary care physicians and specialists—based on location, specialty, symptoms, and in some cases price. Click here to see how it works. Join SAMI-Aid today for free and enter this flu season with confidence. If you join SAMI-Aid Premium, you will gain access to our Intelligent Physician Matching tool. Our friendly concierge team will also go above and beyond to help you with comparing prices and finding the best and most affordable options for all your healthcare needs.


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