Question

Choose and explain one of these topics and discuss the process steps involved in the Medical assistant or other health care provider with the task. Preventing upcoding and down coding.

1. Securing a Prior authorization
2. Obtaining an ABN
3. Justifying a Medical Necessity for a billing code
4. Referring a patient to a specialist.

Answer 1

Referring a patient to a specialist.

A referral is an order, a letter, from a patient’s primary care provider to consult a specialist for a particular healthcare service or opinion. It is a patient’s transfer of care from one provider or clinic to a specialist provider or clinic by request. A referral letter contains the reason for referral and relevant patient history including medications and allergies. Most of the health insurance companies insist on getting a referral to ensure that patients consult the correct providers for their problems.

Referral process steps include:

1. Documentation of the reason for the specialist referral in the medical record of the patient.

2. The patient should be informed about the necessity of a referral. The information regarding the specialist including the address, directions etc should be given to the patient.

3. Contact the specialist and discuss about the patient, need for the referral, strategies etc. A referral agreement detailing the specialist’s roles should be made.

4. Implementation of strategies.

5. A method for referral monitoring should be created with referral report due date.

6. Evaluation of the patient referral and decision making.