Risk Management

Minimize the Risks of Patient Co-Management in Managed Care Plans

[Digest, Fall, 1994]

The role of an ophthalmologist within the managed care system is usually that of a secondary provider. According to the managed care contract, the primary care physician (PCP) is the gatekeeper and is responsible for referring the patient to secondary providers. Utilization protocols of the plan may be in place limiting the ophthalmologist’s ability to directly refer patients to other providers. The following scenario is an example of how problems can develop within this type of system.

Retinal Detachment in a Referred Patient

It is Friday afternoon and an ophthalmologist sees a patient who has been referred for flashers, floaters, and an inferonasal veil O.D. The ophthalmologist contacts the patient’s PCP to request a referral to a particular retinal specialist. The PCP agrees; however, according to the plan contract, the PCP has to see the patient before the referral can be made. The patient is sent back to the PCP’s office. The ophthalmologist calls the retinal specialist at home and gives him a complete description of the patient’s partial detachment.

Meanwhile, the PCP’s secretary calls the retinal specialist’s office and is told that the doctor has left for the day and will return on Monday. Unaware of the urgency of the situation, the PCP’s secretary makes an appointment for the patient on Monday. The ophthalmologist is not informed of the delay in treatment, and the patient suffers a complete detachment the next day.

Referral Form Could Avert Treatment Delay

The referral policies of some managed care organizations create needless bottlenecks, which greatly increase the possibility that a patient will not be seen and effectively treated by the proper health care provider in a timely manner.

A referral note to the patient stating the urgency of the referral might have avoided the delay in treatment and subsequent retinal detachment suffered by the patient in this scenario. (See sample referral note on next page.) A referral note should be printed on NCR paper; the original should be given to the patient and a copy put in the patient’s chart. In addition to communicating information such as the name and phone number of the proper health care provider, the referral note should instruct the patient to contact the referring physician if the appointment is not made in a timely manner.

While it may be difficult in a managed care setting to ensure that patients are always seen and treated in a timely manner, using a referral note shows the secondary provider was concerned enough to take that extra step on behalf of the patient.

Referral Form for Managed Care Patients

Date _________________

Dr. ____________________ has referred you to Dr. ______________________

Phone ______________________________

This referral is:

___ Emergency

___ Urgent (24-48 hours)

___ Timely (1-2 weeks)

___ When convenient

This appointment will have to be made for you by your primary care physician, Dr. _____________________________, who has been notified. If there are any problems scheduling this appointment, please contact this office.

For office use only:

Outcome ___________________________________

(Original to patient. Copy to chart.)