Referrals

Part of being a PCP is knowing one's limitations, and that's where referrals come in. A medical referral is a formal request for another opinion from a specialist. Traditionally, this meant sending your chart to another doctor so that you could visit them, and they could make an informed decision or perform a procedure that that the PCP isn't equipped for.

This isn't the mark of a poor PCP - indeed, one person can't do it all and it's unsafe to expect it. With that said, there are a few common misconceptions about referrals and specialists. For commonly dealt-with complaints such as hypertension, diabetes, depression/anxiety, sprains & everyday musculoskeletal complaints, the average PCP can manage these easily. Indeed, PCP's often get more experience dealing with run-of-the-mill issues than specialists who only end up seeing unusual or complicated cases.

Your PCP should be open to a discussion about placing referrals - indeed, they should initiate that discussion if it's necessary. For patients with multiple specialists, the PCP should act as the coordinator and quarterback. Commonly, specialists can get tunnel vision on their organ system of focus while neglecting you as a person

Insurance Logistics

Different insurance companies require different processes for referrals, however. Some allow patients to directly contact specialists and set up appointments on their own. The advantage of this is that if a PCP doesn't have availability, the patient's care doesn't get delayed. The disadvantage is that issues which could have been dealt with by the PCP then block availability for issues that truly require a specialist. It also risks the patient going to the wrong specialist due to a misdiagnosis or presumed diagnosis. Other insurances require an official referral to an "in-network" specialist, which the PCP would order.

TRICARE has a process that's something of a hybrid. Annual exams with optometry, well woman exams with gynecology, physical therapy, and mental health services are often a "self-referral," though that depends on where your Military Treatment Facility (MTF) is placed and what resources it has. Your PCM (Primary Care Manager) also cannot put in referrals - they can only request that administrators place referrals, which is why there is often a more than week's delay between your PCM putting in the order and it being released to the insurance network. They also can request certain providers, but the administrators can choose whether to abide by this request or to put in a different one. Because of this uncertainty, I've included the below information:

To find out where your referral has been sent with TRICARE:

If TRICARE West: either call 1-844-866-9378 OR go to your regional website @ TRICARE West,

If TRICARE East: either call 1-800-444-5445 OR go to your regional website @ TRICARE East

If Overseas, Contact Your Regional Call Center