If an enrollee seeks health services from a non-managed care panel specialist without a referral from the primary care physician, this is known as what?

The situation described involves an enrollee accessing health services from a specialist outside of the managed care panel, without going through the primary care physician for a referral. This action is termed "self-referral."

In a managed care setting, referrals are typically required to control costs and ensure appropriate care pathways. When an enrollee bypasses this process and directly seeks care from a specialist, they are essentially taking the initiative to refer themselves. This often occurs in situations where patients feel they need specialized care immediately or believe they are knowledgeable enough about their health to seek out specific expertise on their own.

The concept of self-referral can impact the cost management strategies of managed care organizations, as services accessed this way may not be covered as comprehensively as those obtained through proper referral channels. Understanding this term is essential for navigating health insurance and billing practices, as it influences both coverage decisions and billing processes in managed care environments.