Does every consultation require a referral be submitted to MSP? How often does a referral need to be submitted? How do you know if a no-charge referral is reasonable? What happens if a consultant sees a patient who has not been referred? How long does a patient remain a referred case?
If you have been baffled with the complexities of the referral process and have questions such as these, you will be pleased to know that the Tariff Committee’s Consultation Working Group recently undertook a comprehensive review of the current payment rules related to referrals and consultations. The result is a substantial FAQ document answering numerous questions that MSP and Tariff have received over the years. The idea was to be as thorough and as clear as possible with the answers.
In the review, five running themes were identified and pulled out for specific clarification:
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.
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.
Referrals, once accepted, do not expire. Once a referral is accepted it remains valid until the consultation is performed.
A consultation must be medically necessary and include the components listed in the MSC Payment Schedule.
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.”
These FAQs will be updated as new questions arise and as new information becomes available. If you have any questions, please contact: