There have been many misinterpretations of the referral-consultation process in British Columbia. In this blog, we will provide a breakdown of the process to help give a better understanding of the MSP billing payment rules for consultations and referrals.
We have broken the post into three sections:
1. MSP Billing Definitions for the Referral-Consultation Process
Let’s start off with defining the terms of the referral-consultation process as defined by the Ministry.
A consultation applies when a medical practitioner or health care practitioner, in 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. Essentially, a consultation is the consultant’s response to a referral.
In this context, the term “health care practitioner” includes:
- Chiropractor, for orthopaedic consultations;
- 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.
Aside from the regular full consultation, there are also limited and special consultations.
A limited consultation requires all the components expected of a full consultation for that specialty but is less demanding and normally requires substantially less of the medical practitioner’s time than a full consultation.
A special consultation applies when an ophthalmologist, neurologist, pediatric neurologist, or neurosurgeon refers a patient to an ophthalmologist for special examination, or when an ophthalmologist refers a patient to another ophthalmologist where a decision regarding medical or surgical treatment is complicated and requires extra consideration, judgment, and implementation of specialized knowledge and experience.
A referral is a request from one practitioner to another practitioner to render a service with respect to a specific patient. Such service usually would be a consultation, a laboratory procedure or other diagnostic test, or specific surgical/medical treatment.
A transferal involves the transfer of responsibility for the care of the patient temporarily or permanently. When one medical practitioner is going off call or leaving on holidays and is unable to continue to treat his/her cases, medical practitioners who are substituting for that medical practitioner should consider that the patients have been temporarily transferred (not referred) to their care.
2. Payment Rules in the Referral-Consultation Process
There are specific MSP billing payment rules that referring physicians must follow for consultations, referrals, and transferals.
Payment Rules for Consultations
To request the opinion of a medical practitioner for advice, the practitioner must provide the following requirements:
- A letter of referral that includes:
- The reason for the request
- Relevant background on the patient
- Notify MSP of the referral and include:
- The practitioner number of the specialist who the patient is being referred on their associated FFS claim
- Note: If there is no FFS claim, the physician must send a “no charge referral” claim under fee item 03333 to MSP
- Generate the report within 2 weeks of the date-of-service.
The consultation includes the initial services of a consultant necessary to enable him/her to prepare and render a written report, including his/her findings, opinions, and recommendations, to the referring practitioner.
Other Requirements for Consultations
- Consultation cannot be claimed unless it has been specifically requested, and the written report is rendered.
- Consultation for the same diagnosis is not normally payable as a full consultation unless an interval of at least six months has passed since the consultant has last billed a visit or service for the patient.
- For consultations and/or other specialty limited services to be paid by MSP, the medical practitioner rendering the service must be certified by or be a Fellow of the Royal College of Physicians and Surgeons of Canada and be so recognized by the College of Physicians and Surgeons of British Columbia.
It is expected that the limited consultation, when medically necessary and specifically requested, will be billed as part of continuing care, and that a full consultation is not billed simply because of the passage of time.
A new and unrelated diagnosis can be billed as a full consultation without regard to the passage of time since the consultant has last billed any visit or service for the patient.
A limited consultation may be payable within the six-month interval, if medically necessary and a consultation has been specifically requested.
Specific additional conditions may apply to specific types of consultation, as designated in the Preamble to the pertinent section of the MSC Payment Schedule and/or the notes to the specific listings.
Payment Rules for Referrals
A referral is required to bill any consultation. The referring practitioner must provide the following requirements:
- There can be only one consultation for any one referral. Another consultation will require a second referral.
- When the medical practitioner to whom a patient has been referred makes further referrals to other medical practitioners, it is the usual practice that the original referring medical practitioner be informed of these further referrals.
Note: Referrals, once accepted, do not expire. Once a referral is accepted it remains valid until the consultation is performed.
Payment Rules for Transferals
For transferals, the practitioner must provide the following MSP billing requirements:
- The medical practitioner to whom a patient has been transferred normally should not bill a consultation for that patient. However, when the complexity or severity of the illness requires that the medical practitioner accepting the transfer reviews the records of the patient and examines the patient, a limited or full consultation may be billed when specifically requested by the transferring medical practitioner.
- A new consultation is not allowed when a group or physicians routinely working together provide call for each other.
3. Overview of the Referral – Consultation Process
To demonstrate how the process works, we have shared a step-by-step illustration of the MSP billing referral – consultation process. The first three steps are completed by the referring practitioner and the last 3 steps are completed by the consulting physician.
Step 1: Inform the Patient
Prior to requesting a referral, referring physicians should ensure that their patient is fully aware of the purpose of the referral and that the patient provides their consent to the referral, and can ask questions about the referral.
Step 2: Complete Written Request
The referring physician should then make a timely, written request for consultation that includes the following information:
- patient’s name, personal health number, preferred and current contact details (Note: If patient has consented to email communication with the referring physician, inform the consulting physician of that consent.)
- date of referral • specific purpose of the referral
- relevant clinical information (e.g., current medications, allergies, health history, physical examination) and social information (e.g. language barriers, gender identity)
- level of urgency of the referral
- expectations about the consultation outcome (e.g., medical opinion only, treatment, transfer of care, other)
- copies or summaries of pertinent laboratory investigations, imaging and other consultant reports
Physicians referring a patient after a telemedicine visit must complete a standard primary care history and arrange for any necessary physical assessments prior to referring the patient to a consulting physician. It is not appropriate for the referring physician to send the same referral letter to multiple specialists concurrently hoping that one will accept the referral, as this can result in wasted time, inefficiencies in the process, and annoyance for both patients and colleagues.
For an example of an appropriate referral request letter, click here.
Step 3: Send to the Consulting Practitioner
After the referring practitioner has completed the request, they can send the written referral request to the consulting practitioner.
At this step, you would also need to notify MSP of the referral and include the practitioner number of the specialist who the patient is being referred on their associated FFS claim.
It is recommended to complete this step within the 2 weeks of the date of service.
Step 4: Consulting Practitioner Responds
Once the referral has been received by the referring practitioner, it is recommended that the consulting physician respond as soon as possible to a referral request with a notification alerting the referring physician that the referral has been received.
The consultant should provide an informative response to the referring physician either accepting or not accepting the referral no later than 2 weeks after receiving the referral.
- If the referral is accepted: In most situations, the consulting physician is best suited to communicate the appointment date and time to both the referring physician and the patient.
- If the referral is not accepted: An explanation of the reason(s) for not accepting the referral should be provided, along with suggested alternatives, if appropriate.
The consultant should advise the patient of any specific requirements prior to the appointment (e.g., bowel preparations, fasting, etc.), and communicate expectations about office procedures (e.g., cancelling or confirming appointments in advance).
Step 5: Send a Written Report
Upon seeing the patient, the consultant should provide the referring physician with a timely written report (the MSP billing fee guide requires that the report be provided within two weeks, except in extraordinary circumstances). Verbal notification should be provided if the results are urgent or critical.
The report should include the following information:
- patient’s name
- if known, the identity of the patient’s primary care physician
- the date of the consultation
- the purpose of the referral as understood by the consultant
- information considered, including history, physical findings and investigations
- diagnostic conclusions (definitive/provisional; differential diagnosis where appropriate)
- treatments or interventions initiated, including medications prescribed or diagnostics ordered
- recommendations for follow-up by the referring physicians
- recommendations for continuing care by the consultant
- recommendations for referral to other consultants
- advice or next steps provided to the patient
Consulting physicians should assume responsibility for informing the referring physician of any subsequent interventions or interactions with the patient, and when a consultation will extend beyond one appointment. Interim reports to the referring physician should be provided as required.
Both the patient and referring physician should be notified when a consultation is complete and patient care is being transferred back to the referring physician, or another care provider.
For an example of a referral received letter and an appropriate referral response letter, click here.
Step 6: Continuing Care by Consultant
Once a consultation has been rendered and the written report submitted to the referring practitioner, this aspect of the care of the patient normally is returned to the referring practitioner.
However, if by mutual agreement between the consultant and the referring practitioner, the complexities of the case are felt to be such that its management should remain for a time in the hands of the consultant, the consultant should claim for continuing care according to the MSC Payment Schedule pertaining to the pertinent specialty.
Where the care of this aspect of the case has been transferred, except for a patient in hospital, the referring practitioner should not charge for this aspect of the patient’s care unless and until the full responsibility is returned to him/her. For hospitalized patients, supportive care may apply.
Continuing care by a specialist (following consultation) normally is paid at the pertinent specialist rates. However, continuing care requires that a written update of the patient’s condition and care be appropriately reported to the referring practitioner at least every six months, until the responsibility for this aspect of the patient’s care is returned to the Primary Care practitioner.
Have questions about the MSP billing referral-consultation process? Contact us today!