When To Refer A Patient To A Specialist

The role of the primary care provider is to serve as a generalist in managing their patients’ health. Specialists are available to provide expert opinion or specific procedures beyond the scope of the primary care provider. Ideally, most patient complaints would be handled by their primary care provider, whether an internist, general practitioner, pediatrician, nurse practitioner or physician assistant. If you have some health issues then you should search for when to refer a patient to a specialist.  

The trend for PCPs to refer more of their patients to specialists, as well as the tendency for patients to bypass a PCP entirely and self-refer to a specialist, has implications for managing quality, cost, and overall outcomes within a patient population.


When To Refer A Patient To A Specialist

The variability in referral patterns can lead to under-referral as well as over-referral. Under-referral can lead to patients not getting the expert opinion and care that they may need to treat their condition, while over-referral can lead to higher risk and unnecessary cost. 

when to refer a patient to a specialist

Your patients may ask to be referred to specialist because they:

> Have health insurance and wish to claim for their treatment (including mental health therapy)
> Want to pay for their own private treatment
> Want a second opinion on their diagnosis or treatment plan from a private healthcare professional
> Want a health assessment to help them make improvements to their health and lifestyle

It is acknowledged among most specialty groups that up to one-third of procedures are medically unnecessary and expose the patient to unnecessary risks. Physicians may also use a specialist to mitigate their own liability that could occur with a missed diagnosis or allegation that they are not doing everything possible to treat the patient. This trend towards specialist referrals is likely to continue as medicine becomes more complex.

The patient’s visit to a specialist is often outside the direct control of the PCP. Most health plans do not require patients to get a referral from their PCP to obtain specialist care.  This makes it even more imperative for a strong physician-patient relationship in which the PCP can guide patients towards the best treatment and specialty care, when needed. Patients who do not regularly visit their PCP may be more likely to self-refer to specialists than patients with a chronic condition that regularly visit the PCP.

Since specialty care will continue to dominate healthcare market, it is imperative for PCPs to have information that will help them make decisions that are in the best clinical and financial interest of their patients. This includes referrals for routine procedures such as colonoscopies, one of the most common reasons for a medical referral. This type of procedure may have low variability in quality, but high variability in cost. 

Referrals for the care of chronic conditions, such as diabetes, heart disease, and cancer are even more significant, since the costs are higher, as well as the variability in both cost and quality.


Specialist cost and quality indicators can be gathered from the electronic health record, as well as administrative claims data. Risk-adjusted preventable events, such as hospital readmissions and emergency room visits, as well as post-discharge follow-up and medication adherence rates can all be calculated using medical claims data.

Primary care physicians serving adults consider several factors to be of major importance when choosing a specialist. The importance of patient convenience, previous experience with the specialist, specialist board certification, and insurance coverage accepted by specialist varied by physicians’ race and sex. A better understanding of factors important to a diverse physician workforce may help to improve the referral process.

We are expanding specialty appointment capacity to make access even faster and have recently added online appointment scheduling in several departments for added convenience. We offer innovative care delivery options in several specialties, including real-time electronic consults with some specialists from your PCP’s office, visits at home that can help to avoid emergency department visits when appropriate, and other forms of telemedicine.

Healthcare providers specialize in treating patients who are obese or overweight. The healthcare providers may also be surgeons. Surgeons are trained to do surgery that aids in weight loss. Healthcare provider will create a treatment plan for you based on your medical needs and preferences.

Most health plans do not require patients to receive a referral from their PCP to acquire specialist care. This makes it more critical for a solid physician-patient connection where the PCP can direct patients towards the very best therapy and specialty care, when required. Patients who don't regularly see their PCP might be more inclined to self-refer to experts than individuals with a chronic ailment that frequently stop by the PCP.


As the trend towards high deductible health plans accelerates, patients are increasingly accountable for the cost of their healthcare treatment. As the trend towards value-based care continues, PCPs are increasingly accountable for the total cost and quality of care delivered to their patients. Both trends mean that a more standardized and transparent method for PCPs and patients to make the best choices possible for specialty care will be mutually beneficial.

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