Question:
Do I absolutely have to have a PCP referal?

I have Cigna HMO, and I called my PCP today to get an appointment for a referral, and there was no appointment that I could get into before my meeting with the surgeon on the 21st of January. The soonest they have was the 22nd? Can I pay for this visit out of my own pocket? Does it have to be referred? I really do not want to lose this date with the surgeon, because the next one they have available is the 14 of February. I don't want to wait that long for this process to begin. Does anyone have any suggestions?    — Kylie E. (posted on January 13, 2003)

January 13, 2003
Yes, with an HMO you must be referred by your PCP. However, you may be able to call his office and explain the need for a referral and they may just call it in for you.
   — Sharon H.

January 13, 2003
It all depends on the relationship you have with your PCP. If I need a referral to a specialist, all I have to do is call and leave a voice mail on the practice's voice mail. I've always gotten the referral. Talk to your doctor - if you have discussed this surgery with him previously, he may give the OK to have his office process the referral for Cigna...JR
   — John Rushton

January 13, 2003
Hi KE. With HMO, you do need a PCP referral. However, this doesn't always mean you must actually see the PCP first. Normally a phone call will work. Call the PCP and let the desk person know what you are considering. She can talk it over with the doctor/nurse and they can write a referral letter and mail it to you and/or the surgeon. They should note in their records that they referred you (in case the insurance company questions). At that point you can carry the letter with you at the time of your visit with the surgeon, unless the PCP mailed a copy to them beforehand.
   — roryleigh

January 13, 2003
What the previous poster is describing sounds more like the Medical Summary letter that my surgeon wanted me to bring to my first visit. All an insurance referral involves is the PCP's office entering the provider # of the specialist in the insurance company's computer base along with the number of visits authorized...JR
   — John Rushton

January 13, 2003
Yes, you will need a referral!! The only time that you can get an over the phone referral to a specialist is when you are going to be seen by a panel doctor who is capitated. Specialist that are paid fee for service, as bariatric doctors are, need to go through a utilization review committee. That is why it takes so long to get the authorization. When you have the support of your pcp and he writes a strong summary on the autho request then it gets approved the quickest, because that along with co-morbidities is what they are looking at. There are instances when you can get a retro autho that will still pay for your visit, but you run the risk of being liable for the bill if you keep the appointment without the autho. When a person signs with an HMO then you have to remember that it stands for health management organization and that is what they are going to do. The HMO's when they pay for this surgery pay for everything in its entirety and in the long run saves you an incredible sum. Even if you were to be put off for three weeks, it is worth it to stay within the guidelines of the group you have chosen. Take the money you save and put it towards your new wardrobe.
   — Sue A.

January 13, 2003
hi there :) i have hmo and called my pcp 2 days before thanksgiving 01. by the saturday after thanksgiving, my referal had already been reviewed and aproved by the medical group to see the surgeon. my referal said " patient is 370 lbs has tried several methods of weight loss with only temporary success". best of luck to you. ps, my cousin waited 1 week for her referal and hers stated "patient 320, back pain and shortness of breath with activity". we both were aprroved and have had our surgerys and life is beautiful! :)
   — carrie M.

January 13, 2003
Thanks for all your responses. Another question for everyone...if I go ahead and keep the 21st appointment, can i just pay for it out of pocket? Or should I just go ahead and wait? Thanks again!
   — Kylie E.

January 13, 2003
My surgeon takes my insurance (US Healthcare) and all I had to do was to call my PCP (who I had previously discussed this with) and ask for the referral so that I could see the surgeon. He also wrote a Medical Summary letter that I took with me on my first visit (requirement of the surgeon). <p> I didn't have any utilization review committee or anything of that sort...JR
   — John Rushton