It depends on your insurance plan.
- Medicare: Traditional Medicare does not require any referral or prior authorization. You can come to us directly. We will still check with Medicare to ensure coverage (which it does cover), but no formal auth is needed.
- Medicare Advantage (HMO/PPO plans): Many do require prior authorization for radiation therapy services. As a matter of protocol, our office will submit a request to the plan with details of the diagnosis and treatment. Usually, it comes back approved quickly since it’s an indicated therapy. These plans might also require that you use an in-network dermatologist/radiation provider (which we likely are). They might also require a referral from your primary care doctor to us (some HMO style plans do). So if you have a Medicare Advantage plan through e.g. Kaiser, United, etc., you may need a referral and an auth. We help facilitate that.
- Private insurance (Employer-based or individual PPO/EPO plans): PPO plans typically don’t need a referral; you can see specialists freely. However, many insurers do require prior authorization for radiation therapy – meaning we have to inform them and get a green light before starting. This is to ensure it’s medically necessary (which for a proven skin cancer, it is). We handle that paperwork. You usually won’t have to do anything except maybe sign a release for us to get info. Once authorized, we’ll let you know.
- HMO plans: Yes, usually you need a referral from your primary care physician to the specialist (us) and also prior authorization from the plan for the actual treatment. So if you’re in, say, an HMO like Providence Health Plan or some networked plan, coordinate with your PCP to send a referral to us. Often our staff can prompt that by contacting them with your consult request.
- Medicaid/OHP: If applicable, those often require prior approval too. But again, that’s internal for us to do.
In summary: – Referral – needed if your plan is a gatekeeper model (like HMO or some POS plans). Not needed for straight Medicare or PPO insurances. – Pre-Authorization – common for any insurance to want an auth for radiation. We will obtain that on your behalf by providing clinical info to the insurer. This happens behind the scenes usually and we schedule treatment once it’s approved (which is usually quick for skin cancer).
It’s always wise to check your insurance card or benefits: if it says “Referrals required” or “PCP must coordinate care,” then definitely get that referral. If not, you can come directly.
Don’t worry though – our administrative team is experienced with this and will guide you. We don’t want you stuck with a bill because an auth wasn’t done. So we’re careful to get all necessary approvals beforehand.
So to answer: many plans do require referral/auth, but our office will ensure those are in place. It’s a part of the process we handle so your treatment goes smoothly without insurance hiccups.
