Providing clarity to the referral process

The Medical Services Commission (MSC) requested the Tariff Committee and the Medical Services Plan (MSP) review concerns raised by patients and physicians regarding the re-referral process. 

The Tariff Committee’s Consultation Working Group (CWG) undertook an expedited review of the current payment rules related to referrals and consultations. The CWG focused on common misconceptions and misinterpretations of the MSC Payment Schedule. A concise list of clarifications was developed with input and agreement from MSP. FAQs were created to provide further clarity. 

A single unified and agreed-upon set of answers should benefit everyone: physicians, MOAs, and patients who may receive conflicting advice from various sources; and staff at Doctors of BC, MSP, and HIBC, who may field the same questions but at times provide differing guidance. The clarifications and FAQs are intended to help interpret the language of the Payment Schedule.

Clarifications (CLR)

A. A referral is required to bill any consultation. A consultation is the consultant’s response to a referral. There can be only one consultation for any one referral. Another consultation will require a second referral. (Reference GPPS D.2.1)

B. Generally the consultant returns the patient to the referring practitioner's care after the consultation is complete. However, there is no automatic referral termination after consultation. Patients may remain referred cases indefinitely if there are: medical necessity, agreement between consultant and patient, and ongoing care. Re-referral is not required for a specialist to bill specialist follow up fees for continuing care. (Reference GPPS D.2.5)

C. Referrals, once accepted, do not expire. Once a referral is accepted it remains valid until the consultation is performed. (Reference GPPS D.2)

D. A consultation must be medically necessary and include the components listed in the MSC Payment Schedule. For clinical specialties this will usually include:

  • Review of history and test results,
  • Examination, and
  • A written report. 

(Reference GPPS D.2.1)

E. There is no specific requirement for a visit by the patient to the referring practitioner in order to obtain referral or re-referral. A valid referral occurs, and a consultation applies, when a referring practitioner, “in the light of his/her professional knowledge of the patient and because of the complexity, obscurity or seriousness of the case, requests the opinion of a medical practitioner competent to give advice in this field.” (Reference GPPS D.2.1)

Frequently Asked Questions 

Note: References to the General Preamble to the Payment Schedule are listed as GPPS. References to the Clarifications above are listed as CLR.

General FAQs

Referring Practitioner FAQs

Consulting Doctors FAQs

Patient FAQs

General FAQs

What is the purpose of a no charge referral (03333)?

The 03333 is generally submitted in the absence of any other service fee billed by the referring doctor for that patient; most commonly, when no visit has occurred but a re-referral is being submitted. 

MSP must be informed that the referring practitioner has requested a consultation. If the referred-to field is not completed on another FFS claim then the no-charge referral, 03333, is required to notify MSP that a referral has been made.

The consultant is required to have received a referral in order to bill a consultation.

Reference: GPPS 1B. pg 1-4
CLR E

Is a referral required for a limited consultation?

Yes. A referral is required to bill any consultation.

Reference: GPPS D.2.1
CLR A

Is the referring practitioner required to submit a referral letter to the consulting doctor?

The referring practitioner is expected to provide the consultant with a letter of referral that includes the reason for the request and the relevant background information on the patient. 

The referring practitioner is also expected to complete the referred-to field on a FFS claim. If no FFS claim is being submitted, a “no charge referral” claim under fee item 03333 is to be sent to MSP.

Reference: GPPS D.2.1

Once submitted, how long does a referral remain valid? For example, a patient is referred on January 1, 2018. A consultation appointment is not available until August 1, 2018, 7 months after the referral was received. Does this patient require a new referral?

Once any referral or re-referral is accepted, it remains valid until the consultation takes place.

Once the consultation is performed, the patient remains a referred case until the specialist discharges
them from continuing care. After discharge, a new referral will generally be required by the consultant
in order to book a new consultation.

Reference: GPPS D.2
CLR C

If the original referring doctor retired or is no longer practicing, is the referral still valid? 

Yes. If the referring doctor has retired or is no longer practicing the referral remains valid. 

The generic practitioner number 99957 (referral by retired/deceased/moved out of province physician) is used in place of the MSP practitioner number in the referred-by field of the consultation claim. 

Reference: GPPS 1B. pg 1-5

Can referrals come from out of province?

Yes. Referrals made by doctors practising in another province use 99998 as the referring MD number. 

Referrals made by a doctor in BC who has now moved out of province use 99957 as the referring MD number.

Other situations in which the referring practitioner does not have a valid MSP number are listed in the General Preamble along with the appropriate MSP numbers to use when billing.

Reference: GPPS 1B. pg 1-5

Can referrals come from another country?

No. Referrals from another country are not valid for billing purposes.

Can referrals be made by non-medical practitioners?

Referrals can be made by non-physician health care practitioners as indicated in the General Preamble:

  • chiropractor, for orthopaedic consultation;
  • midwife, for obstetric or neonatal consultations;
  • nurse practitioner;
  • optometrist, for ophthalmology consultations;
  • optometrist, for neurology consultations for suspected optic neuritis or amaurosis fugax or anterior ischemic optic neuropathy (AION) or stroke or diplopia;
  • oral/dental surgeon, for diseases of mastication;
  • registered nurse or registered psychiatric nurse, for addiction medicine or psychiatry consultations for substance use conditions;
  • podiatrist, for orthopaedic consultations

Reference: GPPS D. 2.1

Can a doctor refer to their locum?

No. Your locum substitutes for you in all respects. You cannot refer to yourself.

If the locum performs a consult on a patient, can they bill a consultation?

Yes. If the absent doctor would perform a consultation on a new case, so does the locum.  However, if the patient is an already-referred case, for which the absent doctor has already performed a consultation, the service being provided is a follow-up, not another consultation. The locum substitutes for the absent doctor and therefore would be following-up with the patient in place of the absent doctor. 

I saw a patient on the weekend as a replacement for their regular doctor. Can I bill a consult?

Yes. If you are referred a patient when acting as your absent colleague’s substitute, and the patient is not already a referred case in that practice, then you are performing and may bill a new consultation providing the requirements for a consultation have been met.

When covering for another doctor you are providing substitute services in place of the absent doctor. This includes providing follow-up services for the absent doctor’s patients. These are billed as follow-up visits.

Reference: GPPS D
CLR A, D

I see the required elements in a consultation include examination, but how can we meet that requirement when we're seeing patients virtually?

Virtual care is well defined in the Payment Schedule. Virtual consultations will usually, but not always, include virtual examination. You are not expected to perform an in-person physical examination for a virtual consultation. 

The expectation is that the doctor will use their best judgement to provide effective and optimal medical services within the constraints of the specific encounter. 

Reference: GPPS D.1
GPPS D.2
CLR D

Referring Practitioner FAQs

Does the referring doctor always have to submit a claim to make a referral?   

Yes. The referral is submitted to MSP by the referring practitioner either by completing the referred-to field in a provided service claim, or by submitting a 03333 if there is no associated service claim. The referral is required in order for the consultant to bill the consultation.

Reference: GPPS D.2
CLR E

Do I have to re-refer a patient to a specialist using a no charge referral (03333) if more than 6 months have passed since the patient’s last visit to that specialist?

A referral is not required for the specialist to see the patient for continuing care beyond 6 months. If, however, you feel a new consultation is medically necessary, then you would normally re-refer the patient.

The 03333 is the correct FFS claim for referral if you have not seen the patient and have not submitted any other claim. If you are submitting another FFS claim for this patient, the “referred-to” field can be completed with the specialists’ MSP number, therefore there will be no need to also submit a 03333. 

Reference: GPPS D.2
CLR E

Am I required to submit a no charge referral (03333) for a specialist to see a patient to follow up on the same problem for which they were originally referred?

A referral is not required if the patient is being seen by the specialist in follow up for the same issue for
which they were originally referred and for which the specialist is continuing to follow the patient at
intervals of less than 6 months, and you are not aware of any change in your patient’s condition which would require a new consultation by the specialist. The patient remains a referred case for that specialist, and the specialist may continue to bill specialist follow up fees.

If the specialist determines that a new consultation is medically necessary within 6 months of the last service provided by that specialist to that patient, the specialist should define the situation for the referring doctor.

Reference: GPPS D.2.5
CLR E

A specialist requests a no charge referral. I have not seen the patient for this issue since they last saw the specialist. I could refer without seeing the patient by submitting a no-charge referral.  If I see the patient just to get paid to refer, is that a waste of time and tax dollars?

A patient visit is not needed to make every referral. The visit should occur only if the referring practitioner feels it is medically required for the patient to be evaluated prior to making the decision about referral. 

A no charge referral is used to notify MSP of a referral when you have not seen the patient.

Reference: GPPS 2.1
CLR E

How do I discern if a no charge referral request is reasonable, if I believe the appointment is actually to follow up on an existing issue, and not for a new issue?

The referring practitioner should be sufficiently aware of the need for consultation such that, in their opinion, referral is medically necessary. 

If the last consultation letter from the specialist provides sufficient medical grounds, or if information from your patient provides you with the evidence that a new referral is medically necessary, it is reasonable for you submit the no charge referral, or 033333. 

If, in your opinion, consultation is not medically necessary, then you should not refer the patient. It is acknowledged that this can be a difficult discussion with your patient if they believe the referral is needed. It can also make relations with consultants more difficult. 

Appropriate and professional communication between care providers is encouraged, and you may wish to reference this document in such conversations, should they occur.

Reference: GPPS D.2.1
CLR E

Can a specialist bill a full consultation after a no charge referral (03333) has been submitted, even though a new request has not officially been made by the referring physician? 

The submitted 03333 is officially a new request from the referring practitioner. If more than 6 months have elapsed since last service to this patient, or if the new referral is for a new and separate condition, a full consultation will generally be billable. Otherwise, a limited consultation will apply. 

If no referral has occurred, the specialist may not bill any consultation fee.

Reference: GPPS 1.B, D.2
CLR A, D

Does my submission of a no charge referral affect whether the specialist can bill a consultation vs. a follow up visit?

Yes. A referral is required to bill a consultation. Without a referral, visit fees will apply.

Reference: GPPS D.2.1
CLR A

Family physicians are often asked to make referrals so that specialists can book a new consultation. However, often these are actually follow ups, not new consultations. Do we need to re-refer patients every 6 months for follow-up visits?

A referral is not required for the specialist to see the patient for continuing care regardless of time frame.

After consultation, further visits to the specialist for the same diagnosis at intervals of less than 6 months can continue to be billed under specialist follow up fees. Re-referral is not required for ongoing specialist follow-up care.

However, either the referring doctor or the specialist may determine that a new consultation is medically necessary, and re-referral is required within 6 months of the last service. Circumstances could include a new diagnosis, or a significant change in condition from the time the patient was last seen by the specialist

A patient sees their specialist every 6 months for a recurring issue. The specialist requires a re-referral for every visit, which means the patient has to see their FP to obtain a referral each time. This causes a delay in their appointments with the specialist. How should the FP handle this?

A referral is not required for the specialist to see the patient for continuing care regardless of time frame.

Under the circumstances described here there is no requirement for a visit by the patient to the referring practitioner in order to obtain referral or re-referral. This is the purpose of the no charge referral, 03333.

However, either the referring doctor or the specialist may determine that a new consultation is medically necessary, and re-referral is required. Circumstances could include a new diagnosis, or a significant change in condition from the time the patient was last discharged from the specialist’s care.

Reference: GPPS D.2.1
CLR E

If the specialist is seeing a patient every 2-3 months, do I need to keep submitting a referral?

Re-referral is not required for a consultant to provide regular continuing care at specialist rates, regardless of duration. 

Reference: GPPS D.2.5

In a group FP practice, can a male FP refer female patients who are uncomfortable with male doctors to a female FP in the group for consultation?

No. Patients expressing a preference for a particular FP in a group practice are not being referred for consultation. The elements which define a consultation are absent.

Reference: GPPS D
CLR D

Can a physician bill a patient directly for providing a referral letter?

No. There is a no-charge referral claim, 03333, with value set at zero. The referral may also be submitted by completing the referred-to field on any other submitted fee. In either case, the service is insured (although the current value is at zero). You may not charge an MSP beneficiary for an insured service.

Reference: GPPS C.1, C.13

Consulting Doctor FAQs

Does every consultation require a referral?

Yes. A referral is required to bill any consultation. The consultation is the consultant’s response to the referral. There can be only one consultation for any one referral. Another consultation is billable only after another referral.

CLR A

How does the consultant know if the referring practitioner has notified MSP that a referral has been requested?

The consultant is not expected to know whether or not the referring practitioner has submitted a referral to MSP. However, the consultant will perform any consultation based on having received a referral themself, and that referral proves they are correctly billing a consultation. 

Furthermore, the consultant is required to notify the referring practitioner of their consultation, and the record of having so notified the referring practitioner proves the consultation was correctly performed and billed.

Can a specialist see a patient without a referral?

A specialist may elect to see a patient without referral. The specialist may submit a claim to MSP for the appropriate family physician visit fee and in addition may charge the patient up to a maximum of the differential between that fee and the specialist consultation fee. As specialists generally have consulting practices that accept only referred cases, this circumstance is very rare.

Reference: GPPS C.14

If a patient was previously referred to me and now needs a new referral but hasn’t been able to obtain one, can I bill another consult by entering the previous referring practitioner’s practitioner number on the new claim?

A consultation cannot be billed unless specifically requested by the attending practitioner. The first referral was completed by the first consultation. A new referral is required for you to bill a new consultation.

A specialist may elect to see a patient without referral (see C1).

Reference: GPPS D.2.1
CLR A

As a specialist, how would I bill if I choose to see a non-referred patient?

Any specialist’s practice may choose to see non-referred cases. Consulting practices provide consultations only for referred cases. Without a referral the specialist is acting not as a consultant but rather as a primary care specialist.

For a non-referred or patient-referred case on the first visit, the applicable FP (primary care) fee may be billed to MSP by the specialist,  and in addition the differential between that fee and the specialist consultation fee may be charged to the patient.  

Specialist follow-up fees are also generally billable only for a referred case. Follow-up fees for a non-referred case should continue to be billed from the FP visit schedule.

Reference: GPSS C.14
GPSS D.2.1
CLR A

I see a patient once every 3 months to manage their condition. If the patient has a flare-up, which I attend to during one of our ongoing visits, can I bill a limited consultation without another referral from their FP?

No. A referral is required to bill any consultation. Without another referral, no consultation is billable. In this case you are describing a follow-up visit.

Reference: GPPS D.2.1
CLR A

A patient was referred to me in consultation for a specific issue. During a follow-up appointment for that same issue, the patient brought up a separate issue for which I don't have a referral. I decided to attend to the patient’s separate issue during that appointment, as it would take too long for the patient to obtain a referral from their FP and wait for another appointment with me. In this situation, can I bill a limited consultation?

1. If you manage the separate issue on this follow-up visit, since there is no new referral for this new issue, you cannot bill either a full or limited consultation. You may bill one of either the appropriate follow-up fee for the diagnosis for which the patient was scheduled to see you that day, assuming you have dealt with that issue as well on this visit, or you may instead bill a non-referred (FP) visit fee for the second diagnosis if it is unrelated to the first issue.

OR

2. You have the option to inform the patient they have not been referred for the new diagnosis so you cannot consult on that issue on this visit. The FP can then decide whether or not to refer for the second diagnosis. If you then see the patient within 6 months in consultation for the now referred
second diagnosis, you may bill a full consultation if it is unrelated to the first condition. If the conditions are related, you may bill a limited consultation.

It is reasonable to provide the patient’s requested consultation even though the original referral was for a different problem. The patient and consultant are both present, the time has been made, and the problem is within the consultant's expertise. Provided all the usual elements of consultation are met, it is appropriate to bill the consultation for this service.

Reference: GPPS D.2

A patient is referred for one problem, but at the initial consultation they indicate that problem has cleared up and they request consultation for a new and different problem. Can I provide the patient's request consultation? 

It is reasonable to provide the patient’s requested consultation even though the original referral was for a different problem. The patient and consultant are both present, the time has been made, and the problem is within the consultant's expertise. Provided all the usual elements of consultation are met, it is appropriate to bill the consultation for this service.

When a specialist sees a patient for an issue, then doesn’t see the patient again for another 18 months, is it appropriate to bill a consultation, if it’s a flare-up of the condition the patient was referred for 18 months ago?

Yes. If the referring practitioner makes a referral, regardless of any time interval, then consultation is appropriate. In the situation described here a full consultation is appropriate but would require re-referral. This may require communication between the specialty office, the patient, and the referring office before the consultation is booked.

Within 6 months of the last service for the same case by the consultant, a limited consultation would normally apply. At any interval of more than 6 months since the last service to this patient a full consultation would normally apply if, in the opinion of the consultant, it was warranted.

GPPS D.2
CLR A

Some patients with chronic illness are referred to the same specialist every 7 months and  the specialist bills a consultation.  Is there any plan to eliminate the referral requirement and allow specialists to provide ongoing care and bill a full consultation every 7 months?

If a consultation is medically necessary, in the opinion of the referring practitioner, then a referral is required.

For those cases requiring ongoing follow-up care such that the patient is seen by the specialist at regular intervals, the specialist may continue to bill specialist follow-up fees.

Reference: GPPS D.2
GPPS D.2.5
CLR A
CLR B

A specialist sees a patient for a consultation, then books the patient to return in 7 months for another consultation.

If the specialist then bills another fee for the same patient in the time between the first appointment and the future appointment, does that ‘reset the clock’? Does the specialist then have to change the next consultation to a date 7 months after the fee that was billed in the interim?

It is inappropriate to book the next consultation at the end of the first consultation. The specialist should not be booking another consultation without a new referral. The decision to make a new referral is that of the referring practitioner, not the consultant. The new referral should occur only when and if the referring practitioner, in the light of his/her professional knowledge of the patient and because of the complexity, obscurity or seriousness of the case, requests the opinion of a medical practitioner competent to give advice in this field.

There should be no concept of “resetting the clock” in order to receive higher fees. Patients should be served when medically required. It is inappropriate to adjust patient bookings based solely on higher fees.

Reference: GPPS D.2.1
GPPS D.2.5
CLR B, D

Specialists sometimes book a patient at the end of the visit whom they would like to see beyond 6 months, and then request a re-referral from the FP.  Can I book the patient for an appointment prior to receiving the re-referral?

The decision to re-refer rests with the referring practitioner, not the consultant. It is inappropriate to book the next consultation before a re-referral from the referring practitioner has been received.

It may be appropriate for the consultant to recommend to a referring practitioner further services, including another consultation at a given time interval, if medically necessary. The reasons for that recommendation should be clearly communicated to the referring practitioner and to the patient.

Reference: GPPS D.2
CLR D

I see certain patients annually for medically necessary reasons. However, obtaining annual referrals for these patients can be challenging. How do I approach these situations?

The specialist should define the situation for the referring practitioner in the previous consultation letter, including the precise reasons why an annual consultation is medically advisable. It is then the referring practitioner’s responsibility, in conjunction with their patient, to determine the medical need for the next consultation, and, if it is deemed necessary, to make the referral. Without a referral, no consultation may be billed.

Reference: GPPS D.2
CLR A

When does the consultant’s role end with a given patient, and how does that get re-established when needed?

Specialists generally do not retain patients indefinitely. They will usually discharge patients from their practice, returning them to the care of the referring physician, once their consulting role is completed.

In general, for most consulting practices, once the patient has been discharged from care and more than 6 months have elapsed since the last service was provided to that patient, the consultant’s practice will require re-referral in order to resume the professional relationship.

How long after the initial consultation does the patient remain a referred case?

If continuing care is ongoing by the consultant, this can continue to be a referred case without any specific time limits. Once the consultant has discharged the patient from their care, this is no longer a referred case and would generally require re-referral and a new consultation for the consultant to resume care for this patient. (See C3.)

Reference: GPPS D.2.5
CLR B

If a referral is made to a clinic, can any doctor take on the referral (e.g. sleep apnea clinic, cardiac care unit etc.)?

A referral is made to specific doctor, not to the overall clinic. Referral claims contain a “referred to” field where the referred-to practitioner’s number is required.

Technically, if another doctor, such as a locum or a partner in the practice, performs a consultation on a case referred originally to a different doctor in the group, the referring practitioner’s practice should be contacted so that a new referral to the correct consultant can be submitted, generally as a no-charge referral.

Practically speaking this will rarely be required as the system will accept that the referral occurred and was originally directed to one of the other doctors in the group.

In a specialist group practice, can a male doctor refer female patients who are uncomfortable with male doctors to the female specialist in the group for consultation? The patent was originally seen by a male doctor in the practice.

It’s stated that the male practitioner in the group has already seen this patient, presumably for the initial consultation. Therefore, the male practitioner is not referring the patient another consultation; he is asking a female colleague to see an existing patient for problem(s) for which the female practitioner is better suited. This is an already-referred case and the service provided is follow-up, not a new consultation.

 

Patient FAQs

My specialist says they need to see me every 7 months for my condition. That means I need to go back to my family doctor every 7 months just to get the referral. Those visits take a lot of time and seem unnecessary. What can be done to change this?

Your specialist should clearly define for you and your family doctor the reasons that your medical problems require regular reassessment at such precise intervals. If your family doctor is in agreement with the medical necessity of those repeated assessments, then they may refer you without requiring you to attend their office. If your family doctor does not agree with the medical necessity of those repeated assessments, they may choose to not make the referral.

There is no specific requirement in the  Medical Services Plan for your family doctor to see you to make a referral for a problem which is well known to all parties and which is not being assessed or managed by your family doctor.

Reference: GPPS D.2.1
CLR E

What if I have difficulty obtaining a referral, because I don’t have a family doctor?

For patients without a family physician: Pathways, the provincial public directory, has information about family physicians accepting new patients, and virtual care options including virtual care clinics.

Reference: Pathways Medical Directory: pathwaysmedicalcare.ca

I have concerns about going to my family doctor’s office during the pandemic, but I need a referral. What should I do? 

These days most family physicians are available for virtual visits (video and phone) when appropriate. Give your doctor’s office a call to find out what their options are for virtual care.