How Delayed Specialist Referrals Affect Outcomes

When your referral to a specialist is delayed, it can increase your ultimate healthcare costs. Even worse, delayed referrals increase mortality rates and may substantially worsen patient outcomes. Patients who seek quicker referrals are often hindered by physician burnout, which includes significant administrative tasks. In many cases, the referral process also becomes slower due to insurance companies dragging their heels.

Disease Progression Harms Patients

Every time a patient misses the window for early intervention, it leaves them exposed to a more aggressive form of their illness. For example, if you wait a long time for a referral to an oncologist, your cancer could become irreversible in the interim.

Unfortunately, even those who do receive a timely referral may not be able to receive quick care. Between “lost” referrals, fragmented communication and administrative troubles, it’s estimated that as many as 50% of referrals aren’t completed. In most cases, this has nothing to do with patient willingness to receive care. Instead, it highlights the healthcare system’s broader operational inefficiencies.

Referrals and subsequent care can also be hindered by insurers. There are many reasons an insurer may provide for denying a referral, but ultimately, it adds up to delayed care. In 2020, a doctor published a letter in Canadian Family Physician that found 36.4% of patient requests for a consult never even received a response. In the U.S., it can be even worse.

Increased Emergency Room Usage

Ideally, those who have a medical condition would receive quick and easy referrals. However, this isn’t an ideal world. Instead of reserving the emergency room for actual emergencies, it can become clogged up with those who are unable to get a specialist referral. If they got specialist management for their condition instead, emergency room wait times would decrease, thereby improving outcomes for everyone involved.

Increased Financial Burden

The process of receiving care in the U.S. can be cost-prohibitive. Even if that wasn’t the case, though, delayed referrals often lead to longer recovery times, more complex interventions and/or hospitalizations. At the end of the day, this boils down to an increased financial burden being placed on the individual who needs care.

Cancer costs in the U.S. are known to be exorbitantly expensive, and this becomes worse with delays. In fact, first-year costs for cancer typically range from $30,000 to $100,000. Today’s extremely high co-pays, deductibles and specialized prescriptions can already place a burden of between $15,000 to $30,000 on patients. If you happen to be uninsured, it will cost you around $85,000+ out of pocket. Now, take these figures and add in delayed referrals, and you’re easily looking at a life-ruining amount.

Why Won’t My Primary Care Physician Give Me a Referral?

In some instances, care is delayed by a doctor’s refusal to grant a referral in the first place. This could stem from several reasons, including a misunderstanding of your symptoms. Other common causes include insurance restrictions and medical decisions.

If you’ve got a note from a previous physician about your medical condition, be sure to give it to your current doctor. It’s also a good idea to provide any recent test results, along with any updated symptoms. However, if your doctor still refuses to give you a referral, you have three primary options:

• Request a self-referral to an in-network specialist
• Switch your Primary Care Physician (PCP)
• Request a second opinion

Having to go through these steps could cause significant delays to treatment. If it turns out you were right and needed a referral, you may even consider getting a medical malpractice lawyer on your side like the experienced attorneys from McCoy & Hiestand, PLC. Although this won’t change your prognosis, it may help you recover from financial damages.

What Should I Do if My Insurer Refuses a Needed Referral?

When you’re dealing with cancer or another serious medical condition, the last thing you’ve got is tons of time. Despite this, your insurer may refuse your referral. If you need immediate care to protect your health or even keep you alive, your physician may request a 72-hour expedited review. Please note that this requires your doctor to take time out of their day and go to bat for you.

There are also two other options. First is to check your Explanation of Benefits (EOB) to uncover the reason your referral was declined. It may say something like “out-of-network” or “not medically necessary.” Getting declined for these reasons when you seriously need healthcare is not only frustrating but puts your health at risk. Many insurers will try to decline referrals as a way of saving money, too.

Secondly, you can file an internal appeal with your doctor’s assistance. Of course, the time it takes to submit additional medical information or get a peer-to-peer review may exacerbate your symptoms. Let’s also not forget about the extreme stress this process can put you under.

Problems Involved with Denied or Delayed Referrals

Aside from everything previously mentioned, a delayed referral wastes your doctor’s time and effort. Furthermore, if your insurer denies your referral, it could slow down the process until after your condition becomes irreversible. Keep in mind that the rising usage of AI to deny claims can make it even more difficult to receive medically necessary care. The person who will suffer the most, though, is you.

What Reasons Do Insurers Use to Deny Claims?

Finally, let’s take a closer look at the techniques insurers often use to deny referrals:

• Failed step therapy
• Internal criteria discrepancies
• Administrative errors
• Out-of-network specialists
• Plan exclusions

Failed step therapy means your physician didn’t try less invasive and/or less expensive treatment methods first. This reason is especially egregious, as only you and your doctor can decide what treatment method may work best for you. In fact, having to waste time with lesser medication or lack of a referral may, once again, delay medically necessary care. Therefore, be ready to ruthlessly advocate for yourself to receive the appropriate care and level of treatment.