Billing as Specialist

[Steve Verno]

This could be possible.

The individual patient's benefit may have this as a requirement pursuant to their contract with the insurance company, no matter what type of coverage they have.

Your best evidence of the plan and the plan's requirements is to look at the patient's health benefit manual.  

Mrs Johnson may have PPO coverage through ABC Insurance and her policy may allow her to seek care from a specialist with no referrals, authorizations or precertifications.  Mrs. Johnson's PPO coverage was obtained through her employer Qwikee Mart

Mrs. Munster may have PPO coverage through ABC Insurance, but her policy requires authorization, precertification  or a written referral to anyone outside the PPO.  Mrs. Munsters PPO coverage was obtained through her husbands' employer Mockingbird Funeral Home. 

Welcome to the wonderful, wacky, world of medical billing.  

[carlanguero]

The practice I work for is Endocrinoly and Infectious Diseases, they do the billing through a billing agency. They have been told we must get a "referral note" from the refering doctor otherwise the insurances won't pay, even if the plan is a PPO and specially with Medicare. I have never heard something like that, is this correct?
Thanks