How Primary Care Doctors Work with Specialists

From annual physicals to acute care for minor injuries and illnesses that come up, primary care is an essential part of healthcare. But what happens when you need care beyond what a primary care physician or PCP can provide?

What Is Primary Care?

Primary care is typically the first point of contact between a patient and the healthcare system. It encompasses a variety of services, including both preventive and acute care. In general, primary care physicians are considered generalists (though many also have subspecialties). They are capable of diagnosing and often treating a wide variety of complaints — from musculoskeletal injuries to chronic illnesses to digestive and endocrine issues to cardiovascular, respiratory and mental health conditions.

Primary care providers (PCPs) specialize in family medicine, general internal medicine, or general pediatrics, according to the American Academy of Family Physicians. PCPs may also be referred to as general practitioners, family medicine doctors, pediatricians or internal medicine doctors. Providers can also include nurse practitioners and physician assistants.

Ideally, patients will visit their PCP at least once a year for a wellness checkup or “physical,” in addition to appointments for other health concerns that may come up. But what happens if you develop new symptoms, a severe injury or are concerned you may have a complex illness that requires the attention of someone more specialized?

When do I need specialist care?

If you experience symptoms or conditions beyond what your primary care physician can or is willing to address, you will need to see a specialist to get the most appropriate care. Conditions that often need specialist care may include broken bones, autoimmune disorders, neurological conditions, advanced heart disease and other chronic diseases.

Since your general practitioner is generally your first point of contact for care, you should schedule an appointment with your PCP if you are concerned about new or worsening symptoms. (For emergencies, always call 9-1-1.) It’s okay if you’re not sure whether you need a specialist — your PCP can determine whether or not they are equipped to address your concerns. Because they are more familiar with your medical history, current medication and any ongoing health needs, they can point you in the right direction for any additional care you may need.

How Do I Get Specialist Care?

To see a specialist, patients (especially those in an HMO) may need a referral, which is a pre-approval that allows you to get specialty care. In most situations, getting a referral is dependent upon your health insurance plan.

Patients with a PPO insurance plan may be able to “self-refer,” meaning they can schedule an appointment with a specialist themselves. It’s still smart to contact your PCP first — they may be able to recommend a specialist for you. It is also wise to verify that a new specialist is covered under your health plan. You can confirm this by checking your insurance provider’s website or by calling the specialist’s office.

HMO patients often need a referral from their PCP, which means the first step toward getting specialty care is an appointment with your PCP. If a referral is warranted, your PCP will refer you to a specialist in your HMO’s network.

If you’re not sure whether you need a referral, contact your insurance provider by calling the number on the back of your insurance card or visiting their website. When you see a different specialist in the future, you may still need a new referral from your PCP.

Specialist care is often associated with a higher co-pay, which is another reason it’s a good idea to confirm with your PCP that you are seeing the right specialist for your needs.

How Does My PCP Work with Specialists?

Even if you end up needing care from multiple specialists, your PCP’s role does not end at the referral. Specialty care is also not a replacement for primary care, and seeing a specialist does not mean you stop  seeing your PCP. Remember, your primary care doctor should be there for you as an ongoing resource for your health care.

Ideally, your specialist and PCP will have ongoing communication with each other about your treatment plan. However, you may have to facilitate that communication or even share your treatment plans between them. Do not assume that your doctors are talking or sharing – you may have to be proactive. Keep your primary care doctor apprised of what’s going on with your specialist care and your specialist apprised of what’s going on with your primary care.

Does My Insurance Cover Specialist Care?

Health insurance is complicated; the costs associated with specialty care will vary depending on your coverage, deductible and other factors. It is always best to check directly with your insurance provider to find out what’s covered.

Specialist Care and MDVIP

Members enjoy many benefits that patients of traditional primary care practices do not — from same- and next-day appointments that start on time to visits that are unhurried to a physician with time to focus on preventive care.

While the average PCP sees thousands of patients, MDVIP-affiliated physicians have a much smaller patient load. This gives MDVIP-affiliated doctors the opportunity to offer longer appointments and build strong patient relationships that can lead to better outcomes.

Just like traditional primary care physicians, MDVIP-affiliated doctors can provide referrals to specialists such as gastroenterologists, neurologists, orthopedists and more. Because they have more time, they may be able talk to a specialist on your behalf.

For patients who need specialized care or second opinions not  available in their area, MDVIP’s Medical Centers of Excellence (MCE) program can connect your MDVIP-affiliated physician with some of the country’s leading medical institutions. Our MCE partners include renowned facilities like Johns Hopkins, Mayo Clinic, and Cleveland Clinic.