What is failure to refer to a specialist?
Asked by: Emely Hoppe | Last update: July 19, 2025Score: 4.8/5 (31 votes)
What to do if your doctor won't refer you to a specialist?
If a doctor refuses to refer you to a specialist, seek a second opinion from another healthcare provider.
Can you sue a doctor for not referring you to a specialist?
Doctors are legally bound to refer their patients to specialists if they can not provide the patient with the necessary care or knowledge to assist them. If you have been directly harmed as a result of your doctor's failure to refer, you may qualify for financial compensation in a medical malpractice lawsuit.
What does it mean to be referred to a specialist?
Your GP will discuss with you and, if appropriate, your carer, about why a referral is being recommended. It is usually because your GP wants a specialist's help in deciding on the best way to treat your condition. This might involve referring you for tests or investigations that cannot be carried out in a GP surgery.
What happens if you see a specialist without a referral?
If you see a specialist without a referral, you may be responsible for the entire bill (not just the copayment or deductible). Where will I be referred for services and specialties? Your PCP relies on a trusted network of specialists to carry out your treatment plan.
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Can you self refer to a specialist?
Generally, you cannot self-refer to a specialist at a hospital within the NHS, except when accessing sexual health clinics or A&E treatment. A specialist will only see you with a letter of referral from your GP.
Which type of insurance does not need a referral to see a specialist?
Exclusive Provider Organization (EPOs)
Most of the time, you do not need to get referrals to see specialists who are in-network. EPOs can have many limits on the doctors or hospitals you can use. With an EPO, you can use the doctors and hospitals within the EPO's network.
What is the purpose of a referral to a specialist?
A referral is a letter from your doctor or health professional to another health professional or health service. Referrals are made to get expert help with the diagnosis or treatment of your health problem.
Do doctors make money when they refer you to a specialist?
In other words, doctors may make referrals, they just can't get paid for doing so. Simply put, a lab may not pay a doctor five dollars for each patient referred to that lab. Each time the doctor receives the five dollar “kickback”, it may be a federal or state crime.
What is the process of seeing a specialist?
Accessing a specialist
If your doctor thinks you should see a specialist, they will write you a referral letter, which needs to be presented to the specialist either before or at your first appointment.
What is failure to refer to specialist?
When you visit a physician such as a primary care or emergency room doctor, they may need to consult with another physician who specializes in a particular area of medicine or refer you to a specialist for proper care. Failing to do so can be considered medical malpractice if you experience adverse effects as a result.
Why would a doctor deny a referral?
Some doctors view a request for a second opinion as a loss of faith in their ability to diagnose and care for you. And, in the high-pressure world of medical care, it may be difficult for your physician to set their ego aside and admit they may have been mistaken in their initial diagnosis.
Is it worth suing a doctor?
Malpractice lawsuits are expensive, time consuming, and can open you up to public inspection. And, unlike most other types of personal injury claims, case trends show a tendency toward favoring doctors and other care providers, not injured plaintiffs.
Can you ask your doctor to refer you to a specialist?
If the reviews are bad or if the wait for an appointment is too long, you can always go back to your doctor and ask for someone else. You're the patient, so your needs are most important. If anything you find out later makes you uncomfortable, you can always ask for a referral to a different specialist.
Do doctors get kickbacks for referrals to specialists?
The Court's Test for Determining Kickbacks in Health Care
Even if the physician was being compensated for some service rendered, if one purpose of the payment is to induce referrals, that is considered a kickback. This can be true for payments made for medical directors or interpreting physicians.
What do you do if your doctor isn't helping you?
If you feel like you're not being listened to, find a second opinion or ask the physician to refer you to a specialist. If all else fails, bring a trusted friend or family member to your appointments to help you make your case.
Why can't you see a specialist without a referral?
Insurance companies make referrals to prevent patients from seeing a specialist for a problem that a GP can solve. They realize that an unnecessary visit to a specialist would cost themselves and the patient extra time and money.
Do doctors get a cut for referrals?
California Law Clarifying Fee Splitting
The statute prohibits physicians and other licensed professionals from offering or receiving rebates, refunds, commissions, or other considerations, as compensation or inducement for the referral of patients, clients, or customers to any person.
Does a doctor have to refer you to a specialist?
Unless you can self-refer, specialists will only see people with a letter of referral from their GP or a hospital doctor.
How long does it take to see a specialist?
Wait times for specialist appointments can vary depending on the type of specialist and your location. On average, it can take anywhere from a few days to several months to see a specialist.
Can you get a doctor referral over the phone?
Telemedicine: Many telemedicine providers can connect you with a healthcare professional who can assess your condition and provide a referral, if necessary. Nurse Practitioners and Physician Assistants: These healthcare professionals can often provide referrals, especially for routine or non-complex specialist visits.
Do you need a referral letter to see a specialist?
No, a doctor's referral letter is not required.
What happens if I don't have a referral?
If you do not have a referral from your primary care physician, your HMO likely will not cover the service. Some modern HMOs have relaxed these rules and allow members to visit specialists within the plan's network without having a referral from their primary care physician.
Why do insurance plans require referrals for specialist visit?
In HMO and POS plans, referrals are necessary for insurance to cover the visit. This ensures care coordination and reduces costs. In PPO and EPO plans, referrals are usually not required, so you can visit specialists directly. However, out-of-network visits may still lead to higher costs.