Consultations, Referrals, and Re-Referrals

Changes to the re-referral process

On July 1, 2023, changes to the MSC Payment Schedule were implemented to improve the re-referral process. In recent years, patients, referring practitioners, and consultants have had increasing problems with re-referrals, particularly when the patient and consultant agree that another consultation is required. 

Background

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 commonly misinterpreted rules around re-referrals and created five clarifying statements along with an FAQ list. However, it became evident that changes to the actual processes were needed to resolve a number of 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 given the ability to effect 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 intent of the Implicit Re-referral (IRR)/Subsequent Consultation (SC) option is to make routine, repeat explicit re-referrals for the same problem unnecessary.

Implicit Re-referral (IRR)/Subsequent Consultation (SC)

The IRR/SC process is a new option, not a mandatory change, which physicians can implement gradually. It is a choice that physicians may use under very specific circumstances for routine planned re-referrals for the same problem and the same circumstances as identified and communicated by the Consulting Practitioner to the patient and to the Referring Practitioner at the completion of a preceding consultation. 

No existing rules have changed. Your practice and/or workflow does not need to alter in any way unless you choose to use this option. 

The anticipated effectiveness of the IRR/SC lies not in its initial use within the next few months, but rather in its continued and repeated use over years of practice. The real power of the IRR/SC is in repetition. The first time the IRR/SC is used it saves one set of unnecessary interactions. Every time thereafter it saves another set. The effect of multiple patients in a single practice each receiving multiple IRR/SCs as medically appropriate over an extended time should be of substantial benefit to 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 with an effective date of 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 specifically requested 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 rereferral” 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 unavailability of the original referring practitioner and their advice to the patient to obtain a new referring and/or primary care provider.

For any questions, please contact . 

Frequently Asked Questions 

Note: The Clarifications and the FAQs related to the Existing Process are currently under review and will be updated to consider the new IRR/SC option.

New process

Implicit Re-referral/Subsequent Consultation – FAQs 

Existing process

Clarifications to existing referral processes

General FAQs

Referring Practitioner FAQs

Consulting Doctors FAQs

Patient FAQs

 

Implicit Re-referral/Subsequent Consultation – FAQs 

Q1. 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.

1. 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.

2. 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.

3. Referrals received after July 1, 2023, contain the IRR/SC option unless it is specifically excluded in the referral.

Q2. 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 the IRR/SC on a case-by-case basis, slowly and gradually. There is no need to rapidly or substantially alter your practice.

Q3. 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.

Q4. What happens if there is a last-minute scheduling change (i.e., a patient calls and needs to change their Subsequent Consultation (SC) appointment date) but the Referring Practitioner (RP) has already been notified of the original SC date and time in the consultation letter?

Nothing needs to change. Continue to manage your practice as you always have. If you are not in the habit of informing Rs of last-minute scheduling changes for booked consultations, SC date changes should be managed in exactly the same manner.

Q5. 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 1 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.

Q6. A patient has a Subsequent Consultation (SC) booked with a Consulting Practitioner (CP) 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, and for which they do not have a referral. Can the consultation for the new issue be provided based on the IRR for the original problem, or would the patient need a new referral?

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.
 

Q7. 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.

Q8. 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 6 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.

Q9. If a consultation is performed on September 1, 2023 and the patient is seen by a technician three months later (i.e. December 1, 2023) for a diagnostic test, would this mean that the Subsequent Consultation (SC) cannot be performed until 6 months from the date of the technician’s service (i.e. December 1, 2023)?

The SC 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 6 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 SC.

Q10. 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.

Q11. 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."

Q12. 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, he/she 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.

Clarifications on the existing referral process

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. 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 one 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 rereferred 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

G1. 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

G2. Is a referral required for a limited consultation?

Yes. A referral is required to bill any consultation.

Reference: GPPS D.2.1
CLR A

G3. 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

G4. 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

G5. 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

G6. 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

G7. Can referrals come from another country?

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

G8. 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

G9. Can a doctor refer to their locum?

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

G10. 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. 

G11. I saw a patient on the weekend as a replacement for their regular doctor. Can I bill a consult?

Yes and no:

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.

And No: If the patient is a previously referred case already seen by your absent colleague, then you are providing a follow-up visit, not a new consultation. You may bill follow-up fees only.

Reference: GPPS D
CLR A, D

G12. 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

G13. If a referral is made to a clinic, can any doctor take on the referral (e.g. sleep apnea clinic, cardiac care unit etc.)?

When a practitioner refers a patient to a group of consultants and it is not known which consultant will see the patient, the referred-to MSP practitioner number can be omitted on the referral claim.  

A referral is required for any consultation; however, the referral does not need to be made to a specific physician. 

The consultation report will identify the consultant. The referring practitioner can then update their records with the consultant’s MSP number. It is not necessary to resubmit the referral.

G14: If a primary care doctor refers to specialist A and submits a no-charge referral to this doctor's MSP but the service is rendered by specialist B in a single entry model, how is specialist B eligible for full payment at the specialist rate? Does specialist A have to submit a no-charge referral to specialist B each time? Or should the office request that the primary care doctor submits it directly to specialist B?”

If a patient is referred to a specific consultant – Specialist A – but the consultation is provided by Specialist B, another consultant in the group practice, then Specialist B can bill the consultation. 

Specialist B will provide the referring practitioner with their consultation report. At this time the referring practitioner can update their records with the Specialist B’s MSP number. It is not necessary to resubmit the referral.

Specialist A does not submit a referral to Specialist B. 

Referring Practitioner FAQs

R1. 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

R2. Should I 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?

If you feel a new consultation is medically necessary after more than 6 months have passed since the patient's last visit to that specialist, then most specialists’ practices would require re-referral to resume care, and 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 specialist’s MSP number, therefore there will be no need to also submit a 03333.

R3. 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

R4. 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

R5. 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 03333. 

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

R6. 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. The referring practitioner is also normally expected to send a referral letter to the consultant. 

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

R7. 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

R8. 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.

If a specialist has arranged for a follow-up visit, then a re-referral is not required, even if it has been more than 6 months. Note that the specialist, together with the patient, determines if a follow-up visit is appropriate and necessary.

If it has been more than 6 months, and a follow-up visit is deemed inappropriate, then the referring doctor, together with the patient, can decide if a consultation is necessary by sending in a re-referral. Circumstances could include the ongoing need for medical advice for a complex, serious, or obscure diagnosis.

Additionally, either the referring doctor or the specialist may determine that a new consultation is medically necessary 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. In these cases, a rereferral is required for a new consultation to be booked by the specialist.

R9. 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 a patient for continuing care regardless of time frame. If a new consultation is deemed appropriate, then a rereferral would be required.

If the referring doctor agrees with a clearly communicated plan and rationale
indicating the need for repeated specialist consultation, there is no need for a
delay in generating a referral because 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.

As well, the Payment Schedule specifically prohibits billing a visit when a patient is asked to attend to obtain a referral.

Reference: GPPS C.5, D.2.1
CLR E

R.10 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

R11. 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

R12. 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

R13. When does the consultant’s role end with a given patient, and how does that get re-established when needed?

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

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, any resumption of the consultant/patient relationship will usually require a new referral.

R14. 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

Consulting Doctor FAQs

C1. 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

C2. 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.

C3. Can a specialist see a patient without a referral?

Yes, a specialist may elect to see a patient without referral. However, as specialists generally have consulting practices that accept only referred cases, this circumstance is very rare.

If the specialist chooses to see a non-referred case, they 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 MSP fee and the specialist’s MSP consultation fee.

Reference: GPPS C.14

C4. 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?

No. A consultation cannot be billed unless specifically requested by the referring 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 C3).

Reference: GPPS D.2.1
CLR A

C5. 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

C6. 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

C7. 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.

Reference: GPPS D.2

C8. 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 usually 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 then bill a consultation for this service.

C9. 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

C10. 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

C11. 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?

More than 6 months must have elapsed since the last date of any service for the same patient by the specialist before another full consultation is billable for the same condition. 

Any practitioner may book patient appointments for any future date. For example, follow up visits can be scheduled at any time interval the practitioner deems is appropriate.  However, a consultation cannot be booked without a new referral. The decision to make a new referral is that of the referring practitioner, not the consultant. 

A 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 the timing of patient bookings based solely on higher fees.

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

C12. For scheduling purposes, is it ok for a consultant’s office to book an appointment for a patient whom they would like to see in the future beyond 6 months, and then request a re-referral from the FP?

The appropriateness of the booking depends on the type of appointment – whether it is a follow up visit or a consultation. 

The Payment Schedule does not dictate scheduling. How appointments are scheduled is the purview of the practitioners’ office.  

Any practitioner may book a follow-up visit for any future date. However, consultations should not be booked before a re-referral from the referring practitioner has been received. The decision to re-refer, and thus create another consultation, rests with the referring practitioner, not the consultant.

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

Reference: GPPS D.2
CLR D

C13. 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 consultant should define the situation in the previous consultation letter to the referring practitioner, 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 new referral. The consultant can book a follow up visit at any interval they deem appropriate (see C11), but another consultation does not occur without a new referral.

Reference: GPPS D.2

CLR A

C14. When does the consultant’s role end with a given patient, and how does that get re-established when needed?

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

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, any resumption of the consultant/patient relationship will usually require a new referral.

C15. 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

C16. 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

P1. 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.

When your family doctor makes your referral, they do not necessarily need to have you attend their office. There is no specific requirement in the Medical Services Plan for your family doctor to see you for any 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

P2. 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.

Additional options include Urgent and Primary Care Centres (UPCCs), which provide access to same-day, urgent, non-emergency health care, or your local walk in clinic. 

Resources:

Pathways Medical Directory: pathwaysmedicalcare.ca

UPCC info (via HealthLinkBC): healthlinkbc.ca/services-and-resources/upcc

Walk In Clinic info (via Find Services, HealthLinkBC) healthlinkbc.ca/services-and-resources/find-service

P3. 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.