Friday, May 24, 2024

Do You Need A Referral For A Specialist With Medicare

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My Friend Recently Had A Procedure And His/her Prep Was Different Than Mine Why

What Is a Referral and Why Do I Need One?

Different physicians prefer different preparations for colonoscopy. You should follow the preparation instructions exactly as it was prescribed for you. Our physicians have a lot of experience in using the different colonoscopy preparations and have decided upon using SUPREPor MOVIPREP because of its low total volume and superior cleansing results. Any questions you have should be directed to our staff.

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$0 Meal Delivery After An Inpatient Hospital Stay

Nutrition plays a critical role in maintaining optimal healthand we want to help! BCBSRI offers our Medicare Advantage members a meal delivery program through ILS Meals by Independent Living Systems. Youll get a weeks worth of meals delivered to your doorup to four times a yearwhen you get home from an inpatient hospital stay.

Home delivered meals offer a convenient and affordable way to recover once you are discharged from an inpatient hospital stay. The hospital discharge planner will help coordinate this benefit.

Benefits of the meal delivery program are:

  • $0 copay
  • Meals delivered directly to your home following hospital stays
  • Easy to heat in conventional ovens and microwaves
  • Flash frozen for guaranteed freshness
  • Nutritionally balancedcarbohydrate, sodium, fat, and portion controlled
  • Menus designed and reviewed by registered, licensed dietitians and updated every six months to provide variety

13 Menu types to meet your unique needs

*Indicates heart healthy meal

  • Low-carbohydrate meals recommended to control diabetes
  • Ethnic options*
  • Meals that do not contain fish
  • General wellness*
  • Prepared in adherence to Jewish law
  • Gluten free diabetic*Excluded to control for carbohydrate content
  • Gluten free*Contains less than 20 ppm gluten per meal

For more information on the meals program, call Independent Living Systems at 833-853-8946 and provide your BCBSRI Member ID number. Call Monday through Friday 8:00 a.m. to 6:00 p.m. Deliveries are made Monday through Friday only.

What A Referral Is Used For

Referrals are required by some insurance policies in order to ensure that a patient is using the proper services for the appropriate symptoms. A referral is a written order by a doctor to see a different medical specialist for evaluation and treatment of a certain medical condition or set of symptoms. In order to get a referral, you would go to your primary care doctor and talk about your condition. Your doctor would either suggest that you see a specialist or you would request to see one. Your doctor will then order a referral, often electronically. You will then make an appointment with that specialist and proceed with your care.

While referrals are required by some insurers for the sake of efficiency and reducing medical costs, referrals can decrease a patients ability to see which specialists they would like to see when they would like to see them.

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Factors That Affect Original Medicare Out

  • Whether you have Part A and/or Part B. Most people have both.
  • Whether your doctor, other health care provider, or supplier accepts assignment.
  • The type of health care you need and how often you need it.
  • Whether you choose to get services or supplies Medicare doesn’t cover. If you do, you pay all the costs unless you have other insurance that covers it.
  • Whether you have other health insurance that works with Medicare.
  • Whether you have Medicaid or get state help paying your Medicare costs.
  • Whether you have a Medicare Supplement Insurance policy.
  • Whether you and your doctor or other health care provider sign a private contract.

Prices Are All Over The Map

Does Medicare Require Referrals?

The prices vary widely: Weve found as little as $600 all in, and as much as $8,000 or even more .

There are links to our detailed price lists in this post from .

Here are examples from our community members reporting:

Charge of $3,200 individual paid $370.41: $3,200 was billed and $2,331 was the allowed amount under my health care plan . However, I received a separate bill from my doctor who performed the procedure for $800 and the allowed amount by my insurance was $370.41 which went to my deductible. because they found a polyp the procedure coding changed from preventive to diagnostic, therefore, I was no longer covered under preventive care.

Charge of $8,000 individual paid $800: I spoke to the CEO of the surgical center. He agreed the fee was high but said there is a standard list of prices that he and most centers adhere to.

Charge of $2,312 individual paid $844: Was charged three initial different fees, for MD, facility, and lab work, all reduced via contract, not payment: 426, reduced to 285 1400, reduced to 279, and 486 reduced to 280, thus $2312 overall reduced to $844, zero by carrier.

Charge of $2,722, insurance paid $743, individual paid $1,979: I did not shop around when I did this. Im embarrassed to admit that it hadnt occurred to me to do that. This price check concept is a wonderful service and eye opener for the public. Many thanks.

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What Does Medicare Consider High Risk For Colonoscopy

Medicare covers colonoscopy screenings the most frequently for any high-risk patient.

The Centers for Medicare and Medicaid Services identifies you as high-risk if you meet one or more of the following:

  • Having an immediate family member who has or had colorectal cancer or polyps. Direct family such as a child, sibling, or parent.
  • Have a family history of colorectal cancer a family history of familial adenomatous polyps or having Lynch syndrome.

Do You Look After Kids Feet

Yes, we see children from any age, although we would not necessarily implement any treatment until the age of about 4-5 years old. We treat kids for a number of conditions including, but not limited to, heel pain, arch pain, flat feet, pigeon toes, plantar warts, toe walking, knock knees, bow legs, ingrown toenails and growing pains.

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Coverage For Medications Related To A Colonoscopy

If this laxative is ordered by prescription, Medicare Part D may provide coverage. If you purchase a laxative over the counter, you may be responsible for the total cost of the purchase.Any medications administered during the course of the colonoscopy, including sedatives, will be covered by Medicare as part of the outpatient procedure itself. If medications are required after a colonoscopy to treat any conditions found during the procedure, Medicare Part D would apply toward these drugs as long as they are listed in your plans formulary and are purchased from a retail pharmacy for home use.

Some Medicare Part C Plans Require Referrals

Medicare Basics: Parts A, B, C & D

Medicare Part C offers Medicare members a wide set of choices in healthcare beyond Original Medicare. Original Medicare is a public program the Centers for Medicare and Medicaid manage the Original Medicare program. Part C consists of plans offered by private insurance companies.

The management styles vary with the insurance plans. Some insurers offer HMO plans to control costs for the consumer and promote savings on out-of-pocket expenses.

The Medicare Advantage HMO plans do not use outside referrals. The primary care physician makes referrals only to in-network resources. This structure brings consistent and low prices to the consumer.

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If It Is A Preventive Screening

If you get your preventive colonoscopy from a healthcare provider who participates with Medicare and has agreed to accept assignment for Medicare-covered services, youll pay no copayment or deductible.11 Accepting assignment means that the provider agrees or is required by law to accept Medicare-approved amounts as payment in full. Most doctors who accept Medicare accept these payment terms, but its a good idea to confirm before you get services.

Why Referrals Are Required By Some Medicare Insurance Plans

A referral is a written order from a primary care doctor recommending that you obtain the health care services of a specialist. Insurance providers usually ask for a referral before agreeing to pay for services. This helps ensure:

  • You’re seeing an appropriate specialist for your condition
  • The services of the specialist can be of benefit to you

You dont need a primary care physician to refer you to a specialist if you have Original Medicare, giving you the flexibility to coordinate your own care as you see fit.

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A Few Quick Ways To Identify If Your Emblemhealth Member Needs A Referral

EmblemHealth offers a wide range of health plans. For many EmblemHealth members, referrals are not needed from their PCP before receiving care from a specialist. Still, we know that figuring out which plans require a referral may be confusing. Watch the two-minute video below that shows your practice how to find out if a members plan requires a referral.

During the COVID-19 State of Emergency, all Medicare Advantage members will not need referrals.

Update: Effective December 1, 2020, SOMOS-managed members do not need referrals to see specialists.

Referrals & Prior Authorization

Medicare referrals: Plans, options, and costs

You can get many services without a referral from your Primary Care Provider . This means that your PCP does not need to arrange or approve these services for you. You can search for participating health partners using the Find a Doctor/Provider tool and schedule an appointment yourself. You can also check your provider directory for a list of participating health partners who offer these services.

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What Is The Medicareco

Technically, there is no co-pay for a colonoscopy under Medicare. As stated previously, Medicare will cover the entire cost of a colonoscopy, so long as the procedure is preventative. If any polyps or abnormalities present themselves during the procedure, the procedure will become diagnostic, and you will be responsible for out-of-pocket costs equal to a 20 percent coinsurance.

In terms of co-payments, you would be responsible for a co-payment if your colonoscopy procedure is done in the hospital. If you have Medigap , part or all of your copayment may be covered.

What Do I Need To Bring With Me For My Procedure

Please bring a list of your current medications including over-the-counter medicines, as well as a current copy of your insurance card. It is advisable for you to bring the phone number of the person who will be picking you up after the procedure . Dress in comfortable clothing. Do not wear jewelry or finger nail polish.

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Is There Parking Public Transport And Disabled Access

We understand that parking for appointments can be a stressful hassle. Thats why at all of our practices we made it our priority to have free parking with disabled access.

For disabled accessible parking at North Kellyville, please make your way to the public parking lot for 21 Hezlett Road which is located at the rear of the building

Hills Podiatry Centre Galston is located within Galston Village Pharmacy which is located next door to Aldi. Disabled access parking is available underneath Aldi

Kellyville Village Medical Centre is located within Kellyville Village Shopping Centre which has both street-level and undercover parking. Disabled access parking is available in any of the parking lots connected to Kellyville Village Shopping Centre.

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Two Sets Of Procedure Codes Used For Screening Colonoscopy:

Physician Self-Referral Law

CPT® code 45378

Colonoscopy, flexible, proximal to splenic flexure diagnostic, with or without collection of specimen by brushing or washing, with or without colon decompression

Healthcare Common Procedural Coding System codes G0105 and G0121

G0105 colorectal cancer screening colonoscopy on individual at high risk)

G0121 (colorectal cancer screening colonoscopy on individual not meeting the criteria for high risk.

Why two sets of codes in coding colonoscopy guidelines?

The Centers for Medicare and Medicaid Services developed the HCPCS codes to differentiate between screening and diagnostic colonoscopies in the Medicare population.

Common diagnosis codes for colorectal cancer screening include:

  • Z12.11
  • Z86.010 .

Clinical scenario one:

A 70-year-old Medicare patient calls the surgeons office and requests a screening colonoscopy. The patients previous colonoscopy was at 59-years old, and was normal. The patient has no history of polyps or colorectal cancer and none of the patients siblings, parents or children has a history of polyps or colorectal cancer. The patient is eligible for a screening colonoscopy. Reportable procedure and diagnoses include:

  • G0121, colorectal cancer screening colonoscopy on individual not meeting the criteria for high risk
  • Z12.11, encounter for screening for malignant neoplasm of colon
HCPCS and CPT® screening colonoscopy codes


By Michelle AndrewsJanuary 30, 2018

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Can You Claim Podiatry On Medicare

Podiatry is one of those services that we can very easily neglect. As our lives become increasingly busy, we often put a pause on looking after our own wellbeing, to make sure everything else is taken care of! However, Podiatry is a vital treatment which can help prevent and care for many conditions including arthritis, diabetes, lower limb functionality, nail and even skincare. The best part? Medicare can sometimes cover the costs of the entire treatment or provide partial rebate!


Unfortunately, claiming Medicare rebates for podiatry is not always simple. But we want to help you get the assistance you need! As experienced podiatrists, we believe that it is our duty, to help our patients who battle with foot conditions day in day out, and therefore, we want to help clarify the Medicare rebate process in easy-to-understand terms.

Whilst it may seem a tad confusing at first, once we explain it, youll understand the method to the madness and receive the benefits which you are entitled to!

Primary Care Referrals Mean Youre Not Alone

Your primary care provider helps you make important decisions and can coordinate your care with your entire healthcare team. As a Medicare Advantage member, your PCP will coordinate referrals when you see a specialist, have a test, and receive some other services. Members who have the Healthmate for Medicare plan do not need referrals.

Some covered services do not require a referral, including*:

  • Mental health and substance use services
  • Emergency and urgent care services
  • Retail health clinics

Other services will require a referral, such as*:

  • Allergy office visit
  • Specialist office visit
  • Speech therapy

*This is not a complete list. For more important information regarding referrals, see your plans evidence of coverage. You can find it on our Plan Materials page.

BCBSRI is committed to giving you safe and secure options to get the answers you need.

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Referrals For Specialist Treatment

Patient referrals to a specialist or consultant physician for treatment, not including general practitioners, need to meet certain conditions. The referral must include all of the following:

  • relevant clinical information about the patients condition for investigation, opinion, treatment and management
  • the date of the referral
  • the signature of the referring practitioner.

Referrals dont need to be made out to a certain specialist or consultant physician.

If youre referring a patient, you should let them choose where to present the referral. This also applies to electronic referrals.

Say Goodbye To Referrals For Good

Medicare Advantage Plans

Did you know that you do not need a referral to see a specialist if you have a Medicare Supplement? A referral is a special kind of pre-approval that individual health plan members must obtain from their chosen primary care physician before seeing a specialist or another doctor within the same network. Medicare Supplements are some of the best coverage available and have many benefits.

You can go to any doctor, hospital, or provider in the country that accepts Medicare. You will very rarely have a healthcare cost other than your monthly premium.

A Medicare Supplement plan, however, does have a higher monthly premium than a Medicare Advantage plan. A Supplement may be $100 per month. If you can afford the extra premium, MedicareBob says, You will love having a Medicare Supplement Plan. YM10052101

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Is My Appointment Covered By Medicare Or My Private Health Fund

We accept all in-date GPMP/TCA and DVA referrals addressed to Hills Podiatry Centre . If you have a Medicare referral form from your doctor known as a GP Management Plan/Team Care Arrangement plan), Medicare may rebate you a portion of your consultation fee. The current Medicare rebate amount is currently $55.10. Please note that the full consultation fee of $78.00 is payable at the time of service then the Medicare rebate will be processed straight into you nominated account.

We have a rebate machine at our clinics, which means you do not have to travel to Medicare or fill out a form for your rebate. If you have a GPMP/TCA you will receive the rebate on the spot the same day as your service.

If you have Private Health Insurance and you have Extras cover including Podiatry, a part of your consultation fee will be covered by your insurer. The gap fee will vary depending on your level of cover. Please contact your Private Health Insurance provider to check if you are covered for Podiatry services.

Do I Need Referrals To See Specialists With Medicare

  • 2:00 pm

Generally, you do not need a referral to see a specialist with Medicare. However, the exact answer depends on which type of Medicare plan you have, Original Medicare or Medicare Advantage. Original Medicare prioritizes flexibility and freedom to choose whatever providers and services you need. Certain types of Medicare Advantage plans prioritize cost, which restricts your flexibility. Read on to learn more about which situations require a referral.

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Are There Any Exceptions

Yes, there are always exceptions to the rule! Specialists who provide behavioral health services, such as psychiatrists and psychologists, and are in your health care network do not require a referral from your PCP.

Women also do not need a referral to see an in-network obstetrician-gynecologist for routine care, such as Pap smears and mammograms. Also, visits that the insurance company considers an emergency may not need a referral.

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