Wiki Self-Referrals

[mlemon]

I am curious as to how many practices in this specialty take self-referrals outside of second opinions. It was my understanding that this was not allowed by Medicare and other big carriers. That was our practice rule as well when I began 10+ years ago.

Is this still the case or am I thinking too "old school"? If there are any links/written rules on this....please post here also!

Thanks in advance.

 

[vhester]

self referrals

Hello Billing123,

I don't have any articles to point you to, but there should be some out there. I believe part of HIPAA is to allow for patients to have better portability and access to medical records which would allow them to find medical care wherever they choose (i.e.: self referrals). And the practice of billing a "Consult" (which REQUIRES a referring physician) for every new patient seen by a specialist, has been abolished by Medicare and other "Big Carriers" that you mentioned, so there is no requirement that a new patient have a "referring physician" to bill a New Patient visit like there was for us to bill a Consultation.

On the other hand, in Cancer Care, where many physician's coordinate care between them to maximize the patient's best outcome, there is a great benefit to having personal relationships with those physicians, especially the PCP or Surgeon, so I can understand a practice wanting to only treat patients that are referred to them by known physicians.

I look forward to seeing what others have to say on this subject.


Vernell

 

[mlemon]

Great feedback and points.

Right now we handle self-referrals like this: We make an appointment for the patient and work with that patient to obtain all medical records. We contact the physicians office (with consent of the pt of course) and establish a working relationship with that physician.

We do not bill consult codes for these as they do not meet the requirements. Thankfully we are definitely handling that part accordingly

I am unsure of when the process changed for our practice (its been within the last few years), it was recently brought up again when a claim was rejected from our clearinghouse for a Medicare claim that did not have a referring physician listed.

Although this is not a common occurrence, I wanted to make sure we were following the guidelines. I am also curious to see what other practices are doing.

Thanks!