A Doctor's Recommendation and Kickbacks?

I am hoping for a factual answer to this, perhaps from one’s personal experience: When a doctor recommends a specialist, are they getting kickbacks? It’s odd that a doctor we trust wants us to go to a specific surgeon 50 miles away because “he is experienced in this disease” when really the disease does not really matter in this specific case. The matter concerns a colon-rectal procedure, and there are many who perform this common operation, including a surgeon (and reputable hospital) about 12 miles from our home. We can’t understand why the GI doc would be pushing this one doctor.

Note: We have some experience here as I almost had my entire colon removed, and I was assigned a surgeon on staff. This surgeon was excellent knowing to watch and wait (with CAT scans), and she had the wisdom NOT to operate and keep waiting for the pivotal moment. Although the current circumstances are a bit different, I just don’t see why our doctor would push so hard for this ONE surgeon soooo far away.

Admins: I am looking for factual answers from experiences, not opinions. If this post becomes more opinionated, please move to the proper forum.

No, no kickbacks. IME as an ED nurse, the referring Dr. is calling whomever is on call for that procedure. In this case, because of your prior issues, the referring Dr. may be calling someone with more experience with your particular problem.

not a physician but a dentist. In TX fee splitting(kickbacks) are illegal. Never heard of it but that doesn’t mean it doesn’t happen but isn’t widespread by any means. I recommend specialist because I trust them and they treat my patients well. Proximity has a bit part in the decision.

Fee splitting (kickbacks) is illegal in all states, IIRC. Has been for decades. It’s considered unethical conduct and can get a license pulled.

If you trust the doctor making the referral, put this question to them (without the accusation of a kickback). “Why are you so strongly recommending this surgeon?”

If you don’t trust your doctor, don’t follow their recommendation.

If Medicare or Medicaid are involved in paying any of the bills involved, a kickback would be a violation of the Stark Law and Federal Anti-Kickback Statute. Of course, that doesn’t mean a kickback can’t be involved, but it would be a serious crime if it were. If all of the bills are being paid by private insurance and/or out of pocket, a kickback wouldn’t be a violation of Federal law, but might still be a violation of state law.

I work in the lab industry, so I don’t have direct knowledge of the inner workings of doctor’s referrals, but I know the two big lab companies I have worked for treated all interactions with providers as if the Stark Law and Federal Anti-Kickback Statutes applied.

It’s possible your doctor and the GI specialist have a kickback deal, and that they’re very careful about making sure no Medicare or Medicaid money is ever involved in any of the cases where kickbacks occur, but they’d be walking a tightrope.

So, it’s possible, but I doubt there’s any financial kickbacks involved, unless they’re both out-and-out crooks.

OTOH, doctors are people. They have personal relationships. They like some of their colleagues and dislike others. I know of a number of doctors who specifically send specimens to our lab because they personally know, like, and trust one or more of our pathologists, and a number who specifically don’t send specimens to our lab because they don’t like one or more of our pathologists personally. It’s entirely possible that your doctor is recommending an old med school buddy. Or is pushing you to avoid a local GI specialist that their feuding with.

Would a recommendation like this, absent kickbacks, still be considered bad form in the medical community if it was done for other dubious reasons? For example, the two doctors were sorority sisters back at State? Or they’re poker buddies who play Texas Hold 'Em on Saturday nights? Or their kids go to school together?

An article about kickbacks in the medical field.

More likely a case of mutual hand washing in the form of referrals. I suppose your well being might be a consideration in there somewhere, but my curmudgeon side doubts it.

Direct kickbacks are indeed illegal.
But many doctors are members of ‘physician’ or ‘provider’ groups. If they refer you to a specialist who is also a member of that group, the money you/your insurance pays stays within that group. So at the end of the year, their provider group has a larger income.

I speak from experience on this. Every colorectal doctor knows how to do a colonoscopy. But sometimes things go wrong. A friend of mine ended up with a punctured colon and spent three days in intensive care. A better doctor minimizes that small risk.

But surgeons don’t do referrals to GI docs. Surgeons don’t normally have anything (legal) to offer to GI docs other than good discharge summaries. (Which may well be a consideration).

He may have a list, provided by his employer, of who he is supposed to refer to. If so, he should tell you when you ask. Around here, a GI specialist would have his own list, and would not depend on an employer list. A family doctor working part time as an employee in a big business might have list of people that practice normally works with.

Based on the doctors I know: either he thinks the surgeon/hospital is better, or he just always sends his patients there, and so far the surgeon hasn’t killed anybody.

Now it may be because they get drunk and do drugs together every Friday night, or it may be because the local hospital surgeons think that your doctor kills people and refuse to accept referrals from him: but kickbacks are unlikely, and even mutual hand washing is probably no more likely than mutual masonic handshakes.

I don’t generally refer patients; I’m the one they get referred to. Patients get referred to me because:

  1. The referral MD contacts the hospital that I work at and I am the one who is on call that day.
    1.5) I’m in the same physician group to begin with.
  2. The referral MD has had contact with me before, and I have not yet done anything to antagonize them, and/or our previous interactions have left a positive impression, relative to some other potential provider.
  3. The referral MD has been made aware of my particular and distinctive expertise in some aspect of care because of a) professional networking (giving presentations at outlying centers, conference attendance, participation in interdisciplinary care groups, etc.) b) advertising by my employer c) social networks (word of mouth).
  4. I am the only person within x miles who provides some particular service, and Google tells them this.
  5. It is a truth universally accepted that I am the best of all time, and none need be told this; they know it in their hearts.
  6. The other people they asked turned them down.
  7. All or some of the above.

Frankly, it’s probably #2 more than anything else. Why refer to someone who’s a PITA to deal with, or who is likely to antagonize your patient and reflect poorly on you as the referrer?

I do not have anything to do with billing other than making sure all the boxes are checked for coding purposes. Nobody gets money from me for referrals. As a provider, I would rather have the OP go to the nearby hospital with the doctor they trust than travel to me with a pre-existing case of resentment.

There will usually be a good, patient centered reason for sending a patient 50 miles away. *

Even if your doctor dislikes the local surgeons, they probably wouldn’t do this unless they don’t trust them to do a good job.

*I guess it might make a difference in rural areas where skilled providers may be thinner on the ground, but that is still a patient centered reason.