How Do Doctor Referrals Work?

If you have a specific health problem — like ongoing hip pain — you might wonder what kind of doctor to see. Should you call your primary care physician (PCP)? Or should you look for a bone or joint specialist?

If you want to see a specialist, do you need a referral? And exactly how do doctor referrals work? Here, we break down some of the basics you should know about referrals from doctors.

What Is a Doctor Referral?

A doctor referral is typically a piece of written or electronic communication from one doctor to another. Typically, the referral is from your PCP to a specialist.

Your PCP may ask a specialist to evaluate or diagnose your condition. They may also refer you to a provider for additional treatment, such as physical therapy.

In some cases, you don’t need a referral to see a specialist. The need for a referral varies depending on your health insurance coverage, and for some routine annual exams or screening tests (like a mammogram or Pap test), you rarely need a referral.

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Why Are Referrals From Doctors Important?

Doctor referrals are important because:

  • A PCP may not have the specific expertise to treat your condition. But they can zero in on who could provide the right evaluation and treatment. In the long run, you’ll get the best possible care for your medical problem.
  • The specialist may have answers to basic questions in their field. For instance, if it’s for a specific treatment (like physical therapy), it might include info about how long the treatment should last.
  • A referral lays the groundwork for your appointment with a specialist. It communicates basic information about your medical history and the reason for the visit. Having these facts at hand makes the process of seeing a new doctor go more smoothly and efficiently.
  • Some specialists won’t see anyone new without a referral from another doctor.
  • Without a referral, your insurance may not pay for a specialist visit. Different insurance plans have different rules and requirements.

The Importance of Having a PCP

Your PCP takes care of your overall health. You go to them for annual checkups, management of chronic illness, and any problem that’s not an immediate medical emergency. Your PCP is usually one of the following:

  • A family medicine doctor.
  • A general practitioner.
  • An internist.
  • A nurse practitioner.
  • A pediatrician.
  • A physician assistant.

Typically, your PCP can:

  • Assess how urgent your medical needs are.
  • Keep you up to date with vaccines.
  • Make referrals to specialists when needed.
  • Manage chronic conditions like diabetes, high blood pressure, or asthma.
  • Perform your annual physical.
  • Provide preventive care.
  • Teach you how to make healthy lifestyle choices.

Conditions Where You Might Need a Referral

There are dozens of medical specialties and subspecialties in the U.S. Specialists focus on a disease, a specific organ, or a specific system of organs in the body.

Depending on your medical condition, your PCP may refer you to more than one specialist. As your treatment plan evolves, you may see several specialists.

Some specialties include:

  • Addiction.
  • Allergy and immunology.
  • Cardiovascular disease.
  • Dermatology.
  • Infectious diseases.
  • Medical oncology.
  • Nephrology.
  • Neurology.
  • Pulmonary disease and critical care medicine.
  • Rheumatology.
  • Sports medicine.
  • Urology.

What to Do if You Want to See a Specialist

There are several steps you can take if you think you need to see a specialist.

Talk to your PCP

The first step is to check in with your PCP about whether or not you need a specialist. Your PCP can treat many common conditions. Depending on your medical problem, they may suggest trying other options before referring you to a specialist.

In many cases, your insurance won’t cover a specialist visit without a referral from your PCP.

Get recommendations

Your PCP may recommend a specific doctor or specialty medical practice. Your insurance coverage may limit your choices.

Even if your insurance doesn’t require a doctor referral, you may still want to ask your PCP if there are specific specialists they recommend. They have a wealth of experience and made many referrals to specialists over the years.

You can also ask friends for recommendations (or read reviews on Google) but take such advice with a grain of salt. Whether or not someone recommends a doctor often depends on their specific set of circumstances, which may differ from yours.

Note: If your PCP writes you a referral, you should ask when it expires. In most cases, a doctor referral will come with an end date.

Check your insurance guidelines

It’s important to check with your health insurance company about what visits they cover. Some plans require a doctor referral to see a specialist, while others don’t.

You should also look into co-payments for specialist visits. They may cost more than co-pays for a regular PCP office visit.

Some different types of health insurance coverage include:

  • Health maintenance organization (HMO) and point of service (POS) plans. With these plans, you usually need a referral for any provider other than your PCP. If you get care from someone outside your HMO or POS, your insurance plan probably won’t pay for those services.
  • Preferred provider organization (PPO) and exclusive provider organization (EPO) plans. With these plans, you usually don’t need a referral to see specialists. However, if you go outside the network of approved providers, your out-of-pocket costs will increase.
  • Medicare Part A and B (Original Medicare) for those 65 and over. You usually don’t need a referral from your PCP to see a specialist. But you should make sure the specialist is Medicare-approved because some practices opt out of taking Medicare payments.
  • Medicare Advantage Plan for those 65 and over. Medicare Advantage works with private insurance to offer more choices for coverage, sometimes with additional benefits like eye and dental care. They often have their own networks (HMOs, PPOs, etc.) of health care providers, so you may need a referral., Referral, Link, How to Pick a Health Insurance Plan, Link, Does Medicare Require a Referral to See a Specialist? Link

American Academy of Family Physicians, Consultations, Referrals, and Transfers of Care, Link

National Library of Medicine, Choosing a Primary Care Provider, Link

U.S. News & World Report, How to Choose the Best Specialist Doctor, Link

National Institute on Aging, How to Choose a Doctor You Can Talk To, Link

Association of American Medical Colleges, Specialty Profiles, Link

About UPMC

Headquartered in Pittsburgh, UPMC is a world-renowned health care provider and insurer. We operate 40 hospitals and 800 doctors’ offices and outpatient centers, with locations throughout Pennsylvania, Maryland, New York, West Virginia, and internationally. We employ 4,900 physicians, and we are leaders in clinical care, groundbreaking research, and treatment breakthroughs. U.S. News & World Report consistently ranks UPMC Presbyterian Shadyside as one of the nation’s best hospitals in many specialties and ranks UPMC Children’s Hospital of Pittsburgh on its Honor Roll of America’s Best Children’s Hospitals. We are dedicated to providing Life Changing Medicine to our communities.