With many insurance plans, the patient must get an authorization from the primary care physician (PCP) to see a specialist. This authorization is often called a 'referral". A "referral" does not necessarily mean a consultation has been requested. If the PCP refers the patient with the expectation that the second physician will take over the care for the referral problem, the second physician should bill a new patient visit, not a consult. If the PCP refers the patient to the second physician for his / her evaluation of the patient and recommendation to the PCP on how the PCP should treat the patient, bill for a consult.
In some instances, the second physician may not know who will provide the care until after he / she runs some diagnostic tests or other evaluations. In this case, the second doctor should bill the initial service as a consult. Subsequent visits should be billed as follow-up visits.
When rendering a consultation, it is best to avoid the use of the word 'referral' as in "Thank you for referring patient X to me." Other phrases that are less confusing are:
- "Enclosed is a copy of my consultation report as you requested."
- "The patient was initially seen in consultation on 2/13/98 at the request of Dr. Smith."
- "Thank you for asking us to see and evaluate this patient."
- "Thank you for the opportunity to see this patient in consultation."
For additional information on the criteria for a consultation, please refer to the June 1997 Alert.