Before seeking sub-specialist help first the patient needs an authorization to see a sub-specialist that originates from their primary care physician who is serving as the "gate keeper". No problem of having a gate keeper for cost control and monitoring utilization and outcome criteria, but the big challenge is when a free patient is using his or her own choice to go and see a sub-specialist that he or she liked, got impressed with, or simply have been unhappy with the one they currently have. So, if this patient dares to do that on their own, now the saga continues with a lot of hassle in the process. It begins by first getting the records from the primary care physician who would ask for the NPI number which is a National Provider Number then they would ask about the Tax I.D. number for the business of the sub-specialist then would ask about the billing codes used and the level of billing for office visits. And then they would be asked about what tests the patient is going to have and when are these tests going to be done since the referral is only limited for a certain period of time beyond which would expire.
In the mean time, this courageous patient who is seeking help will be either forced to cancel or at least delay seeking help from a sub-specialists until seeing his or her primary care physician even if the patient confirmed that the sub-specialist is a participating provider in that particular insurance company. So the patient will ultimately not be free to choose even from the limited selection given to them and so many sub-specialists who will be blocked from the gate (i.e no referrals) for that patient even if they have verified all the information about the participating sub-specialist even after going through the investigation and verification process. So the patients ultimately have no choice but to go where ever he or she is directed to only when the "gate keeper" decides to let them through!
As patient advocates and pro choice supporter for patients rights would be certainly violated or at least interfered with every time even when a patient attempts to get a second option for his or her medical condition. Eventually it will be up to the consumer to decide when and where to seek help that they trust without being dictated by the "gate keeper". Or even worse, deny the patients access to any sub-specialist especially with high-risk contracts would mean money out of their pockets if they refer patients out and usual message said to the patients "we will take care of everything for you, you don't need to see any other doctor." There has to be a better way where the main focus is providing the best care to the patients rather than collecting the most money!
Dr Adel Eldin,MD, FACC,FACP
President , Society of Physician Entrepreneur, Tampa Bay Chapter
Low Cost Quality Healthcare Program.
Toll Free 877-DR-ELDIN