A Case for Waiving or Offering Same-Day Referrals for Emergency Situations

A “referral” is the recommendation by a Primary Care Physician (PCP) for an insured patient to receive care from a different participating plan physicians or specialist. With certain New York State insurance carriers, referrals are mandatory before a patient can visit with a participating plan physicians or specialist. Only PCP's, OBGYN's or certain limited specialists may issue referrals, and these referrals take time to coordinate.

Not only are there long delays and wait-times between the PCP visit and the specialty care visit, but the referral process itself is often cumbersome and confusing for patients and physicians alike. Matters are further complicated when the situation is an “emergency” and the patient needs same-day access to a specialist. Often patients are unable to reach their PCPs for the referral or, worse, the PCP’s office is unable to obtain a same-day referral.

The result: patients use the Emergency Room for conditions that could have been treated in a less expensive setting. In most cases, a visit to the ER for a potentially preventable condition is nearly eight times the cost of seeing a doctor, 3.5 times the cost of an urgent care visit and about 15 times the cost of using telemedicine.

So why not offer a method for waiving the referral requirement in an emergency situation or have a system in place for issuing same-day, hassle free, referrals (even if after-the-fact). New York State insurance carriers, please explain?

For more information about potentially preventable Emergency Room visits in New York State, click here.