Where are the referrals ????

If you are a specialty provider, your patients should be responsible for obtaining their own referrals prior to their arrival at your office.  A sign should be posted at your front desk advising all patients that they will not be seen without a valid referral.

In general, patients hate having to obtain a referral each time they visit a specialist.  Their requests often mean an additional visit to their Primary Care provider, along with an additional co-payment just for permission to be treated elsewhere!!!!

Often emergency situations arise where a patient needs to be seen right away and their primary doctor may be away or have a policy that referrals require 24-36 hours advance notice.  Physicians are often reluctant to turn away a patient, especially if their symptoms are cause for alarm, or they are an established patient that the specialist has been following for some time.

Logically these situations all make sense, and no doctor ever wants to turn away patients, but the fact is that lack of a valid referral is one of the main reasons that physicians fail to gain reimbursement for their time and efforts...

A good answer to this problem is a collaborative effort between the front office staff and the patient, and having an established system that promotes this collaboration is key to successful claim reimbursement.

Some practices have their referral system down to a science and obtain the referrals for their patients to assure they receive them in a timely fashion.   This not only is a great help to the patient, but it also helps the specialist to continue a good working relationship with the physicians who refer to their practice.
It's an excellent system and works especially well in practices such as Cardiology, where the patients are often elderly and have more difficulty with the referral process.

Another bonus gained by your practice obtaining referrals for future visits is that you can accurately request the services that will be rendered at time of visit.   For example, if you routinely perform an EKG at time of treatment, you will request that it is clearly stated on the referral.   Making it even easier, you can request that your referral notes "consultation and treatment" so that services rendered will not be denied.   This referral offers the specialist the options of choosing how to manage his patient, without feeling that services needed cannot be performed.

Whatever method you use to obtain your referral, it is necessary for the staff to note the referral number, expiration date, and number of visits allowed into the system or on the encounter or billing sheet.  Many systems will now automatically count down the number of visits that remain for a particular patient and notify you prior to the referral expiration date.  

All paper referrals should list a referral number, the patient ID, date of birth, start and end date, referring physician, and referred to physician.   Note :  Blue Cross requires that all referrals be faxed back to them and will deny claims if they do not have an advance copy on file.

If you require that your patients obtain their own referrals, make sure that you remind the patient when your make your confirmation calls.

As previously stated, despite the most sophisticated EHR system, at the end of your day, before your encounters go to the billing department, a copy of the referral and the Welcome should accompany each claim.   If your billing staff downloads the daily claims electronically, they MUST know the requirements of each plan prior to transmission and know whether or not a referral is required.

Pre-Certification for testing and/or procedures should be noted at the time of verification and all pre-certs should be obtained at the time of insurance verification.   Some of the commercial insurance plans require medical records and recent studies before granting authorizations so it is a good idea to have these on hand prior to requesting authorization.

One way to assure that pre-cert is complete prior to procedures is to assign it to the staff member directly involved in the procedure.   For example, we had a separate check-in and appointment desk for Nuclear Stress testing.   The employee manning this station had the responsibility for obtaining all pre-certifications for the procedure and obtaining medical records when requested.   This formula allows the practice to have once responsible staff member controlling the pre-certification process, as well as the daily testing schedule.   Should a nuclear stress test be denied, there was accountability at this location, or at least a good reason for appeal.

In a group practice, you may want to consider assigning a secretary for each physician.  This assigned employee would be responsible for all referrals and authorizations for her physician.   Either way, you must create an environment of accountability for worked performed in your office.  Your employees need a clear cut definition for their work flow and know exactly what is expected of them each day.

Should a patient need to be seen on an emergency basis, a call to their primary can be made even if they have already arrived at the office.   No claim should be denied for lack of referral or authorization.
Your office manager should review all encounters at the end of each day to assure that no claims go to the billing staff without a 100% assurance that the claim will be paid...