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Frequently Asked Questions About Specialty Referrals

To whom will I be referred for specialty care?

If your Atrius Health PCP determines a specialist is needed for your care, he/she will refer you, whenever possible, to a specialist within Atrius Health, or to a limited group of trusted specialists from outside offices in the event we cannot accommodate your need at our practice.  Over the last few years, we have significantly expanded our in-house specialty services and continue to improve appointment access to meet your care needs.

It is important to understand that for care that requires a referral Atrius Health does not refer to all of the specialists and hospitals that may be included in your health plan’s network of providers. Unless you are in active treatment elsewhere, or if we are unable to provide you with the appropriate clinical expertise within a clinically appropriate time, you will be referred to an Atrius Health clinician.   Similarly when hospital-based care is needed, we refer to our preferred hospital partners. The clinicians at Atrius Health refer within these trusted specialty and hospital relationships to provide you with the most complete and coordinated care.

In Massachusetts, a referral is not required to select an obstetrician, and the same is true for behavioral health services (other than for patients who have Tufts Medicare Preferred HMO as their insurance.)  Atrius Health offers a wide range of obstetrical care, including certified nurse-midwives who work collaboratively with our obstetricians.  We also have one of the largest out-patient behavioral health teams in the area, along with a broad range of other preferred clinicians we work with in the community.

ReferralsImageHow does my health plan product (insurance) affect my referrals?

The rules established by the health plans for referrals vary widely by insurance company and product. It is really important to understand the options and restrictions of any health plan before you enroll and to contact the health plan’s member services to learn what is required before they will pay for a test or specialist.

If you have a managed care health plan (e.g. HMO), these plans expect your PCP to coordinate your care through referrals and do not allow a patient to make his/her choice of specialists.   Your PCP will make the selection of specialists within our preferred relationships that best meet your needs and will then provide the referral.  Other types of health plan products (e.g., PPO, POS) may allow you to pay additional costs to see a specialist other than the one recommended by your physician.

If your health plan requires a referral and you choose to see clinicians outside of approved referrals from your PCP, you will likely be responsible for paying the entire bill (not just a co-pay or deductible). Even if your health plan does not require a referral, we strongly suggest that you call your PCP’s office to assess your needs as a first step in considering the right specialty care.

May I request a referral from my PCP’s office after I have seen a specialist or on the same day as my specialist appointment?

At Atrius Health, referrals must be requested in advance of a non-emergency visit with a specialist and we typically require 3 business days to review referral requests. If you choose to see a specialist without the approved PCP referral required by your health plan, it is likely that you will be responsible for payment of the entire bill (not just a co-payment or deductible). Please note that back-dated or same-day referral requests will usually not be approved by our practice other than for a medical emergency.

What if I am referred to a specialist when I am at another specialist, the emergency room or in the hospital?

You should call your PCP’s office for a referral before seeing a specialist who is recommended by the emergency room or another provider and before following up with a specialist who you have seen at the hospital. This will ensure that we can best facilitate within our connected system any follow-up care that is needed and try to help you to avoid a repeat emergency visit or hospital readmission.

Who do I call if I have a question about a referral?

If you are requesting information about whether a referral is required by your health plan, please call health plan’s member services at the phone number on your health insurance card. If you have a medical question related to a referral, please call your PCP’s office.