Need to See a Specialist?

Need to See a Specialist?

Need to See a Specialist?

Lee esto en EspañolWhen you’re not feeling well, you might call your primary care doctor. With a little care, your doc may have you on the road to recovery in no time. But what if your health issue is more serious? Your primary care doctor may say you need to see a specialist.

What Is a Specialist?

A specialist is a doctor who has additional education and clinical training in a specific field of medicine.

Your doctor may decide that your health issue needs the opinion of a specialist to make sure you get the right diagnosis and treatment. You may also need to see a specialist for treatment after you’ve been diagnosed. In some cases, you will see a specialist until your condition is under control. Afterward, your primary care doctor will provide ongoing care and management of your condition.

Common Specialties

Some examples of health issues that need a specialist’s care include:

  • Arthritis and other joint conditions
  • Stomach and digestive conditions
  • Eye disorders
  • Heart conditions
  • Cancer
  • High-risk pregnancy
  • Mental health issues

The type of specialist you see depends on the health concern. If you have a skin problem, your doctor may send you to a dermatologist. And if you have cancer, you’ll most likely see an oncologist.

There are several hundred medical specialties, including ones you may have heard about but will never need. The U.S. Library of Medicine offers a list of common specialists.   And Yale Medicine explains some less common specialists

Don’t worry about asking too many questions if your doctor mentions a specialty that’s unfamiliar. Ask questions until you have a good sense about what to expect. Here are some tips for talking with medical specialists

Why Not Start with a Specialist?

Primary care doctors are trained to diagnose and treat many health problems. They also know when someone with special knowledge and training is needed for a certain health issues. Unless you have the training of a doctor, you can’t know if your symptoms need a specialist. For example, what you think is a heart problem may be a reflux issue.

Another good reason? Specialists cost you more. Most health plans have you pay a higher copay to see a specialist. Since they charge more, the amount you pay in coinsurance (if you have it) may be more, too. If you haven’t met your deductible yet, you could be paying a lot of out-of-pocket charges you may not have needed to pay if you saw a primary care doctor first.

And depending on the type of plan you have, you may need to get a referral to see a specialist for the visit to be covered by your plan. If you dont have an approved referral for the visit and one is required, you will have to pay for the cost of your care.

Your doctor has experience working with many specialists and can help you find the best one for you.

Do You Need a Referral?

HMO plans and some other health plans require a referral from your primary care doctor or medical group or prior authorization from your health plan. If your plan requires a referral, going to see a specialist, in or out of network, without an approved referral may mean that you’ll have to pay for all of the cost of your care. Talk to your doctor or call the customer service number on your member ID card if you aren’t sure what you need to do.

What’s Next?

Your primary doctor can help you through the process of seeing a specialist. Your doctor’s office can provide a referral if you need one.

And your doctor’s office can check to make sure the recommended specialist is in your network. It doesn't hurt for you to confirm it, too. Seeing providers in your plan’s network helps you get the most from your benefits. Your out-of-pocket costs may be lower when you see network providers. In some cases, you may have to pay the whole bill if you see an out-of-network specialist.

Want to double check? Log into Blue Access for MembersSM (BAMSM) and use the Provider Finder® tool to make sure the specialist is in your health plan’s network. You can also call the customer service number on your member ID card to check. If the specialist is not in your network, ask your doctor to recommend a different one.

Sources: Discussing Health Decisions with Your Doctor,   U.S. Department of Health and Human Services, 2020; Which Specialist Do I Need? Maybe a Doctor You Didn't Know Existed,   Yale Medicine, 2020; Types of health care providers,   U.S. Library of Medicine, 2022

Originally published 12/16/2019; Revised 2023