Question
When is a referral from a PCP necessary?
Answer
Medicare is first and foremost. With Medicare, everything's done under medical necessity. It must be done under the active treatment of the primary care physician. When a patient comes in to see you, you must not test the patient until you have a referral from that primary care physician.
If you test the patient and then call the physician and say, "Hey, I just had Jane Razzlefratz in here. We found some sensorineural hearing loss. Can I get a referral from you so that we can bill Medicare?" Don't do that. That is not at all appropriate. You have to have the referral before you test Jane Razzlefratz, and it should be in writing, on a physician letterhead or a script pad. It can be faxed to you. It can be hand-carried by the patient. It can be mailed to you. But you need to have written documentation, in the event of an audit, so that you can assure the auditor that what was done, from your perspective, was under the guise of medical necessity, by referral of the primary care physician, or the primary treating physician, if you please. Sometimes a request comes from an ENT as opposed to the PCP. So it's got to be a physician referral.
Medicaid also requires a referral of a PCP, but may not be as strict as Medicare, depending upon what state you are in. For example, in Florida, someone who has regular Medicaid or MediPass is eligible to see an audiologist without first going to the physician.
But we are obligated to ensure that what we do falls under the heading of medical necessity, and we are also obligated to keep that physician in the loop as a primary, active, treating physician by providing a report to that physician for what we found and having physician approval for any follow-up recommendations.
HMOs obviously require referral for everything. In the beginning, HMOs were a way to reduce the cost of health care by providing quality care and preventative medicine. I'm not trying to be mean or facetious;just trying to be real. In most recent days, HMOs have moved to the area of [sighs] less service and rationed health care, and that way, will earn more money. That seems like that's become the motto of HMOs. Because of some of the backlash, some HMOs are loosening the referral requirements, but no one has a completely open door to see an HMO patient.
So they still require a referral of primary care for most everything that goes on. A hassle factor, gatekeeper situation.
Now, under this broad heading, I'm going to offer to you a recommendation of what we do here in my office. We started doing this several years ago, and it has proven to be very beneficial so that we're not caught by surprise by denial of payment, or at least not as much as we used to, and the patient's not caught by surprise by a denial of coverage.
And that is, for every patient that comes ingardless of the status, regardless of the payermeone here in the office calls the payer to ensure, number one, that the patient is still eligible under that payer, that the services that we provide are eligible for reimbursement under that payer, and that the person providing the services is eligible to file for reimbursement under that particular contract. Because if the answer is no to any of the above, we need to know that we are not participating providers and we're not eligible to reimburse so that we can weigh if we want to see the patient. Also, the patient also needs to know that the service may not be covered.
And that serves to eliminate any surprises, it's a pre-authorization or prior authorization process, if you please, for everyone who walks through the door. And that has really helped to cover us in cases where we've gotten prior authorization and, if we get a denial, we have a basis for appeal that's much stronger than if we have not gone through that exercise.
Robert Fifer, Ph.D., is the Director of Audiology and Speech-Language Pathology for the Mailman Center for Child Development at the University of Miami School of Medicine. He is also an Audiology Online Contributing Editor in the area of Coding and Billing. He is the ASHA representative to the American Medical Association's Health Care Professions Advisory Committee for the Relative Value Utilization Committee in addition to being ASHA's representative to the AMA's Practice Expense Advisory Committee.
Editor's Note - The above is a partial transcript from the Coding and Billing QNA Live e-Seminar that was conducted on Audiology Online on June 27, 2007. (The recorded version is available here - Also the complete edited transcript is available here. The format of the session was different from most traditional presentations as we solicited questions ahead of time and also solicited questions during the event and had Dr. Fifer focus on answering those questions during the live session. We have published the transcript from the seminar in a semi-rough format to preserve the live feel from the session and to accelerate the publication timeline of this information to the Audiology Online readers. Submitted questions are bolded, followed by Dr. Fifer's response. Dr. Fifer is a frequent Contributing Editor for Audiology Online in this area, look for additional Coding and Billing QNA sessions on our home page in the near future. - Paul Dybala, Ph.D. - Editor
