Getting an Endocrinology Referral in LA with Medi-Cal, Covered California, HMO, PPO or Kaiser Coverage

Being told to see an endocrinologist is the start of a process, not an appointment. A county patient, a Kaiser member and someone with an employer PPO can live on the same street and still take completely different routes to the same kind of specialist. Know your route before you start calling, and you'll avoid false starts.

Start with one call to your plan

Whatever your coverage, the member services number on your insurance card is the quickest way to learn the rules that apply to you. Ask these questions, and write down the answers, the date and the name of the person you spoke with.

• Do I need a referral from my primary care doctor to see an endocrinologist?
• Does the visit need prior authorization, and who requests it?
• Which endocrinologists or clinics near me are in network?
• How long does a referral stay valid, and how many visits does it cover?
• What will I pay for a specialist visit and for lab work?

Medi-Cal

Medi-Cal is California's Medicaid program. It gives free or low-cost coverage to people with limited income. You can apply at any time of year, either online or through Covered California (LA County DPSS). The program covers about 12 million Californians and was expanded starting in 2014 (PPIC).

If you have Medi-Cal, ask your plan or primary care clinic how specialist referrals work for you and which endocrinology clinics accept your coverage. If your care is through LA County's Department of Health Services, the medical-home model described next applies.

The LA County medical home

Los Angeles General Medical Center and Harbor-UCLA Medical Center are part of the LA County Department of Health Services. At DHS facilities, all care, including visits to specialists, is coordinated through the patient's medical home (LA General).

Both hospitals have endocrine services. USC's endocrinology division runs outpatient endocrine clinics at LA General twice a week, one with more of a pituitary focus (Keck School of Medicine of USC). Harbor-UCLA's endocrinology division lists reproductive endocrinology and intermediary metabolism and diabetes among its focus areas. In both cases the request starts with your medical home. If you're new to the system, LA General's main number is (323) 409-1000.

Covered California plans

Covered California is the state's health insurance marketplace, set up under the Affordable Care Act in 2014. It's the only place qualifying Californians can get federal financial help when buying private insurance. But it doesn't sell insurance or pay claims itself (Covered California).

That distinction matters for referrals. Network and referral rules belong to the insurer you picked through the marketplace, so questions about specialists go to that insurer's member services line. If seeing a particular endocrinology clinic matters to you, check that clinic against a plan's network before you enroll.

HMO plans

We haven't yet checked California's HMO referral rules with the state regulator, so we won't summarize them here. What we can tell you is what to ask. Call your plan and your primary care office. Find out who submits the endocrinology referral, whether prior authorization is needed, and how you'll be told it's approved.

Also ask whether your plan assigns you to a particular medical group, and whether that group keeps its own list of specialists. If it does, check the endocrinologist against the group's list, not just the plan's directory.

PPO plans

With a PPO, ask whether you can book with an endocrinologist directly or need a referral, and what you'll pay in and out of network. Confirm both the doctor and the location. Large systems see endocrine patients at many sites. UCLA Health lists seven outpatient locations, and Keck Medicine of USC has a Beverly Hills office as well as Keck Hospital of USC. So check the exact address, not just the system name.

Kaiser Permanente

Kaiser Permanente's Los Angeles Medical Center lists a combined Endocrinology/Diabetes/Rheumatology department (Kaiser Permanente). Members should start with their Kaiser care team and ask how an endocrinology referral works. If you're a member and want to see an endocrinologist outside Kaiser, ask Kaiser member services how that would be covered before you book. If you're not a member, check with Kaiser directly rather than assuming you can be seen.

What your primary care doctor should send

A referral is a request from one doctor to another. The specialist's office uses it to decide whether, where and how soon to see you. A bare referral with a diagnosis code and nothing attached gives the office little to work with and may come back with questions.

Ask your primary care office to include:

• The reason for referral in plain words, and the specific question they want answered
• Recent lab results related to that question, with dates and reference ranges, such as thyroid blood tests or diabetes labs
• Earlier results for the same tests, so the specialist can see change over time
• Reports from relevant imaging, such as a thyroid ultrasound or bone density scan, and where the images are stored
• A current list of medications and supplements
• Relevant visit notes and a short summary of your history
• Your insurance details and any authorization or referral number

If the referral is denied or bounced back

1. Find out whyCall the specialist's office and ask exactly what was missing or why the referral was declined.
2. Close the gapPass that answer to your primary care office and ask them to resend with the missing items.
3. Check the plan sideIf the plan denied authorization, ask the plan for the reason in writing and what your options are.
4. Keep a logNote dates, names and reference numbers for every call. It makes each follow-up faster.

Once you have a name, check the doctor

When you know which endocrinologist you'll see, confirm their California license with the Medical Board of California's License Verification search. Then confirm their Endocrinology, Diabetes and Metabolism certification with the American Board of Internal Medicine at abim.org/verify (ABIM). The home page walks through both checks. For a list of what to bring, see the first appointment guide.