Medicare Compliance & Reimbursement

Some specialists are asking for the moon, primary-care physicians complain

Myth: Consult requests should include every possible scrap of information on the patient.

Reality: When a doctor requests a consult from your specialist, she needs only to list the reason for the consult and ask for the specialist's opinion.
Some specialists have been driving primary care practices insane by asking for too much information, say practices.

The problem: Doctor X requests a consult from Doctor Y. Doctor Y responds by faxing Doctor X a form to fill out and fax back. The form doesn't just document the consult request. It also asks for the patient's insurance information and test results, practices say.

Consulting physicians "are asking for information they should be obtaining on their own or through the chart in the hospital," says Barbara Switzer, executive director of the Northern Physicians Organization in Traverse City, MI. "They say they will not see the patient until they have all the lab work that's been done, all the x-rays that have been done [and] all the insurance information."

"I have seen lengthy forms that specialists want completed," says Melanie Valletta, institutional compliance auditor with State University of New York Upstate.

"The insurance information is just icing on the cake," says Maggie Montgomery, physician reimbursement auditor with King's Daughters' Hospital and Health Services.

But if the requesting physician has already done diagnostic tests, she should send them to the consultant so he won't need to repeat the tests.

"This is causing an enormous amount of work," Switzer adds. Some primary care physicians are responding by saying they won't refer any more patients to some consulting physicians unless the excessive requests stop. "People are going berserk over this topic."

Note: The Centers for Medicare & Medicaid Services (CMS) clarified last year that the consultant doesn't have to make sure the requesting physician's files include written documentation of a consult request. But the consultant should have a written request in his own files, experts recommend.