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Referral

Referral

Overview

Generally, a medical referral is when one physician sends a patient to or recommends that a patient see another physician or other medical professional. In the managed care context, a referral is sometimes required by insurance companies to see any physician or specialist other than a beneficiary’s primary care physician, in order for the care to be covered. The federal physician self-referral [Stark] statute prohibits physicians from ordering “designated health services” for Medicare (and to some extent Medicaid) patients from entities with which the physician (or an immediate family member) has a “financial relationship.”

Authority

The term “referral” under the Stark Law is defined more broadly than merely recommending a vendor of designated health services to a patient. Instead, the term “referral” means, for Medicare Part B services, “the request by a physician for the item or service” and, for all other Medicare and Medicaid services, “the request or establishment of a plan of care by a physician which includes the provision of the designated health service.”

Under the Stark Law, certain referral relationships are deemed not to constitute a referral if the services are furnished by (or under the supervision of) a specialist pursuant to a consultation. Specifically, the Stark Law excludes from the term “referral”: 1) a request by a pathologist for clinical diagnostic laboratory tests and pathological examination services; 2) a request by a radiologist for diagnostic radiology services; and 3) a request by a radiation oncologist for radiation therapy, if such services are furnished by or under the supervision of the pathologist, radiologist or radiation oncologist.

Excerpt from David E. Matyas, Anti-Kickback and Self-Referral, Fundamentals of Health Law (American Health Lawyers Association Nov. 2011).