Addressing HMO PCP Referral Requirements for Specialty Care

Mary Cate Zipprich
Oct 22, 2022
min read


South Central Cancer Center has been working with Incisive Consultants since Incisive’s founding in 2018. Since that time, the number of patients whose insurance requires primary care physician (PCP) referrals for specialty care has increased. These referrals are different than the authorization number that is obtained for a specific procedure, and can be submitted on the claim. The workflow for tracking and attaching these authorization numbers is well established in Epic. The PCP referral is also important because failure to obtain one could result in insurance claim denials or delays in care. The workflow for tracking and attaching these referrals is not standard in Epic.

The Plan

Without a standard way in Epic to track whether PCP referrals have been obtained, Incisive Consultants worked with South Central Cancer Center to design a creative solution. The team decided to use a new referral type called “PCP Referrals.” The financial clearance team won’t be linking these “PCP Referrals” to the visits because those visits will already have order-generated referrals for the procedure or consult attached. However, they will be using them as a visual indicator to track that the necessary PCP referral is on file for the patient.  

The Workflow

Working together with the financial clearance team, we developed a workflow to flag patients with insurance plans that require a PCP referral as part of the financial clearance process for scheduled appointments. Once that flag is set, the financial clearance team confirms that the PCP referral type exists for the patient. Then, the staff uses workqueues to capture referrals with any upcoming visits that have PCPs expiring soon.  

The Challenge

This workflow is not a standard Epic solution and therefore it relies heavily on the training team to help the staff understand the correct process. The project team worked closely with the training team to develop materials and an education plan to help remind the staff to set the PCP referral flag and check for the existence of a PCP referral type.  

A Satisfied Team

The financial clearance team is looking forward to having a solution that helps them better keep track of PCP referrals on file and a way to be proactive about expiring PCP referrals.    

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Mary Cate Zipprich
Mary Cate Zipprich
Patient Access Analyst and Consultant Lead

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