Changes to the re-referral process
In recent years, patients, referring practitioners, and consultants have experienced increasing problems with re-referrals, particularly when the patient and consultant agree that another consultation is required. Changes to the MSC Payment Schedule were made on July 1, 2023, to improve the re-referral process.
How were the re-referral process changes made?
In early 2020, at the request of the Medical Services Commission (MSC), the Consultation Working Group (CWG), comprised of Tariff Committee members and Medical Services Plan (MSP) representatives, BC Family Doctors, and Consultant Specialists of BC, was reactivated to review the problems related to the re-referral process. By 2021, the CWG had identified the most misinterpreted rules around re-referrals and created five clarifying statements and an FAQ list. However, it became evident that changes to the actual processes were needed to resolve underlying structural problems.
The 2022 Physician Master Agreement (PMA) realigned the CWG into the Consultation and Referral Working Group (CRWG) via the addition of an independent Facilitator and Chair, with a mandate to develop changes to the MSC Payment Schedule to address the re-referral problems. In contrast to the CWG, the CRWG was able to enact changes to the MSC Payment Schedule.
The CRWG created an essential new process: the combination of the implicit re-referral and the subsequent consultation. The Implicit Re-referral (IRR)/Subsequent Consultation (SC) option intends to make routine, repeat explicit re-referrals for the same problem unnecessary.
Implicit Re-referral (IRR)/Subsequent Consultation (SC) Explained
The IRR/SC process is a new option, not a mandatory change, which physicians can implement gradually. Physicians may use this option under particular circumstances for routine planned re-referrals for the same problem and circumstances, as identified and communicated by the Consulting Practitioner to the patient and the Referring Practitioner after a preceding consultation.
No existing rules have changed. Your practice and/or workflow does not need to be altered in any way unless you choose to use this option.
The anticipated effectiveness of the IRR/SC lies not in its use within the initial rollout but in its continued and repeated use over years of practice. The real power of the IRR/SC is in repetition. The first time the new process is used saves one set of unnecessary interactions. Every time thereafter, it saves another set. The effect of multiple patients in a single practice, each receiving various IRR/SCs as medically appropriate over an extended time, should substantially benefit all parties.
The new process guidelines, copied below, will be added as section D.2.3 Subsequent Consultation to the General Preamble. The changes will be implemented by the MSC and effective July 1, 2023.
Frequently asked questions on the IRR/SC changes can be found at the bottom of this webpage.
D. 2. 3. Subsequent Consultation
A subsequent consultation for the same diagnosis may be payable as the applicable full consultation when an interval of at least six months has passed since the consultant has last provided an insured service for the patient. All referrals include a potential implicit re-referral for the same problem unless a re-referral is specifically excluded. A subsequent consultation must comply with MSC Payment Schedule D.2. in all respects, with the exception that it does not have to be requested explicitly via an explicit (new) re-referral.
The potential implicit re-referral may be activated, if medically appropriate, to allow the patient and consultant to schedule and conduct one or more subsequent consultations for the same problem unless explicitly excluded by either of the following:
i) The referring practitioner’s referral letter specifically disallows an implicit re-referral by stating: “This referral is for one consultation only and does not include a re-referral” or similar language, OR
ii) The referring practitioner disallows the implicit re-referral via written response to the consultant within 14 days of receiving notification by the consultant of the scheduled date for a subsequent consultation.
Notification by the consultant of the scheduling of any subsequent consultation must be provided to the referring practitioner at least 30 days before the scheduled date and must conform to all other College of Physicians and Surgeons of BC Guidelines and Standards.
Any additional subsequent consultations must follow the same rules. Another Implicit re-referral potentially exists following any subsequent consultation unless the referring practitioner has explicitly excluded it as described above. A subsequent consultation may not be billed if the Implicit re-referral has been disallowed.
If the referring practitioner is no longer in practice a subsequent consultation may be performed if medically appropriate, but the consultant must document the availability of the original referring practitioner and their advice to the patient to obtain a new referring and/or primary care provider.
Implicit re-referral/subsequent consultation FAQs
1. Does the IRR/SC apply to referrals made and/or received prior to July 1, 2023?
The consultation date determines whether a referral made/received prior to July 1, 2023, can contain the Implicit Re-referral (IRR)/Subsequent Consultation (SC) option.
Consultations performed before July 1, 2023, cannot contain an IRR/SC.
Example: Patient A is referred to the Consulting Practitioner on March 1, 2023. The consultation was performed on June 1, 2023. This referral cannot contain the IRR/SC option as the consultation was performed before July 1, 2023.
Consultations not yet performed, for referrals made/received prior to July 1, 2023, can contain the IRR/SC option.
Example: Patient B is referred to the Consulting Practitioner on April 1, 2023. The consultation is scheduled for July 17, 2023. The IRR/SC option exists as the consultation will be performed after July 1, 2023.
- Referrals received after July 1, 2023, contain the IRR/SC option unless it is specifically excluded in the referral.
2. My practice cannot book patient consultations more than 30 days in advance, what do I do?
The IRR/SC is an option. It has been carefully designed and approved with its current rules. If those rules do not fit within your practice’s pattern, there is no requirement that you use the IRR/SC. You may wish to consider trying it on a case-by-case basis, slowly and gradually. There is no need to rapidly or substantially alter your practice.
3. What if I need to book a more urgent patient consultation due to their condition?
This suggests a significant change in the circumstances of the previous explicit referral and consultation. The implicit re-referral is based on the same circumstances as the preceding explicit referral. The IRR/SC is for routine, planned re-referrals for the same problem under the same circumstances of the preceding referral and consultation.
Unpredictable flares, changes, different problems, and any other unanticipated circumstances are outside the IRR/SC. A substantial change should be managed as you have always done so. The IRR/SC option does not apply.
4. What happens if there is a last-minute scheduling change?
Nothing needs to change. Continue to manage your practice as you always have. If you are not in the habit of informing of last-minute scheduling changes for booked consultations, SC date changes should be managed in exactly the same manner.
5. Does the Implicit Re-Referral expire, or can it be repeated indefinitely?
Yes, the IRR/SC can be repeated indefinitely, as long as the rules of General Preamble D.2.3 Subsequent Consultation are met each time. There is no specific time beyond which an IRR, once invoked in the Consulting Practitioner’s (CP) original consultation letter, cannot be renewed. The real power of the IRR/SC is in repetition.
Each time the Consulting Practitioner (CP) performs a Subsequent Consultation (SC), if the Implicit Re-referral (IRR) requirements are fulfilled, the patient and the CP can, by mutual agreement, book and then perform another SC. Each following SC must obey the same rules as the first SC.
Example: Patient A is referred to the CP on May 1, 2023. The consultation is performed on August 1, 2023. The patient and the CP agree it is medically necessary to schedule another consultation for the same problem in one year. The CP's consultation letter to the RP defines the problem with stated medical reasons and advises that the IRR/SC option is being activated. The consultation letter includes the date/time of the SC appointment for Aug 1, 2024, at 13:00. The RP agrees, no further action is required.
The SC is performed on Aug 1, 2024. The patient and the CP agree it is medically necessary to schedule yet another SC for the same problem in another year’s time. The CP's consultation letter to the RP defines the problem with stated medical reasons and again advises that the IRR/SC option is re-activated. The consultation letter includes the date/time of the SC appointment for Aug 1, 2025, at 15:00. The RP agrees, no further action is required, and so on.
Note: Should the RP choose to disallow the SC within 14 days of receiving notification of the scheduled date, the IRR/SC process will end. A new explicit referral would then be required for another consultation.
6. A patient has a Subsequent Consultation booked with a Consulting Practitioner for a specific problem. The patient has since phoned the CP’s office with a new and separate issue for which they are requesting a consultation.
The patient would need a new explicit referral for the new issue, as there can be only one IRR for any one problem or set of problems, which must be defined in the original explicit referral. The implicit re-referral is essentially a duplicate of the preceding explicit referral. A different problem/diagnosis would require a new explicit referral, as is currently the case for any consulting practice. The rules have not changed.
The IRR/SC applies to routine planned re-referrals for the same problem(s) and the same circumstances which existed for the preceding referral and consultation.
7. Does submission of a 03333 automatically include the IRR/SC?
No, it does not. To clarify, a 03333 submitted only to the MSP system is never seen by the Consulting Practitioner (CP).
The CP must first receive a preceding explicit referral to then subsequently invoke an IRR. If the Referring Practitioner (RP) sends an explicit referral to the CP when submitting the 03333 to MSP, then the CP may choose to invoke the IRR/SC option, if appropriate.
If no explicit referral was sent to the CP by the RP upon submitting the 03333 to MSP, no IRR can occur.
8. Does the Implicit Re-referral (IRR) and Subsequent Consultation (SC) apply to Repeat Consultations?
No, it does not. By definition, a Repeat Consultation may be payable within six months of the last date of service, if another consultation for the same problem(s) has been specifically requested. SCs cannot be Repeat Consultations as the SC must occur more than six months after the last date of service for the same problem(s).
Within six months of the last date of service for the same problem no IRR/SC can be invoked. You may provide a follow-up visit or, if a new explicit referral is received, a Repeat Consultation.
9. If a consultation is performed on September 1, 2023 and the patient is seen by a technician three months later (December 1, 2023) for a diagnostic test, does this mean the Subsequent Consultation cannot be performed until 6 months from the date of the technician’s service (December 1, 2023)?
The subsequent consultation by definition must meet the criteria for a consultation, not a Repeat Consultation. A consultation other than a Repeat Consultation can be billed if it is performed more than six months after the last date of the provision of most services for the same problem.
For any test or procedure, the existing rules have not changed. If, in your practice, certain services provided within six months prior to a consultation do not reduce that consultation to a repeat consultation, then those services will also not affect the use of the subsequent consultation.
10. Does the IRR/SC process mean that Consulting Practitioners (CP) cannot discharge a patient?
No, nothing changes. The CP can continue to discharge the patient as appropriate at any time, and follow-up appointments can continue to be booked as always. The IRR/SC is an option.
11. Referring Practitioner and Consulting Practitioner eligibility questions
A. Does the IRR/SC apply to Family Physician consultants?
The IRR/SC applies to any consultant who meets the criteria for providing a consultation. For FPs, requirements are found in D.2 General Preamble and FP Payment Schedule Consultations.
B. Do referrals from other health care practitioners qualify for the IRR/SC?
The IRR/SC includes all Referring Practitioners. Various practitioners can refer. Please see the General Preamble Section B-Definitions of the MSC Payment Schedule, including "Health Care Practitioners," "Referred to Practitioner," and "Referring Practitioner."
12. Have the requirements for a Consultation Report and/or Referral Letter changed?
No, the requirements for both a Consultation Report and a Referral Letter remain the same.
In the case of a Consultation Report, if the Consulting Practitioner (CP) wishes to invoke the IRR/SC based on medical necessity, and the patient agrees, then that information, including the date/time of the scheduled Subsequent Consultation (SC), should be communicated in the Consultation Report or shortly thereafter.
In the case of a Referral Letter, if the Referring Practitioner (RP) would like to rule out an IRR/SC in their Referral Letter, they can state that the referral is limited to one Consultation. Further consultation(s) would then require another explicit referral. This might be common practice for Emergency Department referrals, or for referrals from one consultant to another.
Clarifying the existing referral process
1. What clarifications do I need to know about the existing referral process?
Note: References to the General Preamble to the Payment Schedule are listed as GPPS (General Preamble to the Payment Schedule). References to the Clarifications above are listed as 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 single referral. Another consultation will require a second referral. (Reference GPPS D.2.1)
B. Generally, the consultant returns the care of the patient to the referring practitioner’s care once the consultation is completed. However, if there is agreement between the consultant and patient, medical necessity, and frequent ongoing care, the consultant may continue to provide and bill specialist follow-up services without a time limit. This does not imply that consultants may never discharge patients from their care; they may do so anytime they feel it is appropriate. After such discharge, the consultant will usually require the patient to be re-referred in order to resume care. (Reference GPPS D.2.5)
C. Referrals, once accepted, remain valid until the consultation occurs. When the consultation is completed and the patient is returned to the referring practitioner, they are no longer a referred case. Acceptance of resumption of care by the consultant for that patient would generally require a request in the form of a new re-referral for a new consultation. (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:
1. 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)
2. "If it is not medically necessary for a patient to be personally reassessed prior to prescription renewal, specialty referral, release of diagnostic or laboratory results, etc., claims for these services must not be made to MSP regardless of whether or not a medical practitioner chooses to see his/her patients personally or speak with them via the telephone.” (Reference GPPS C.5)
General FAQs
1. 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. pages 1-4
CLR E
2. Is a referral required for a limited consultation?
Yes. A referral is required to bill any consultation.
Reference: GPPS D.2.1
CLR A
3. 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 an 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
4. 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, seven months after the referral was received. Does this patient require a n
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