11.3 Managing Referred Patients: Continuity, Autonomy, and Gifts From Specialists
Key Takeaways
Under ADA Code Section 2.B, a specialist returns a referred patient to the referring dentist after treatment unless the patient expressly prefers otherwise.
CDA Code Section 9 requires a specialist to reasonably ask whether a prospective patient is already under another dentist's care.
When there is no referring dentist, a specialist must tell the patient after treatment whether further dental care is needed (ADA Code Section 2.B).
California B&P § 650 makes receiving or accepting anything of value for referrals unlawful, just like offering it.
CDA Code Section 11 says undisclosed fee arrangements between dentists or others in the healing arts are unethical.
Continuity of care for referred patients (K2071)
When patients visit or are referred to specialists or consulting dentists, ADA Section 2.B says:
- After completing their care, specialists "shall return the patient, unless the patient expressly reveals a different preference, to the referring dentist, or, if none, to the dentist of record for future care."
- When there is no referring dentist, the specialist must inform the patient, after treatment, of any need for further dental care.
The CDA Code, Section 9, adds:
- A dentist has an obligation to make a reasonable inquiry to determine whether a prospective patient is currently under the care of another dentist.
- To preserve continuity, the specialist must tell the patient about the need to continue care with the referring dentist, unless the patient expresses a different preference.
Good referral practice includes:
- Clear referral letters from the general dentist: the question, relevant history, radiographs, and medications. Sharing for treatment purposes is allowed under Civil Code § 56.10(c)(1).
- Reports back from the specialist: findings, treatment, and recommendations for the general dentist, such as when to place the final restoration after endodontics.
- Coordinated timing so the patient is not left with a temporary restoration or an unrestored implant.
Patient autonomy for referred patients (K2072)
The referral belongs to the patient. The patient may:
- Choose a different specialist from the one suggested, for example for insurance, location, or personal reasons.
- Decide to stay with the specialist for other care, if they expressly say so. The specialist must not recruit them away from the referring dentist.
- Decline the referral after an informed discussion. The general dentist documents an informed refusal (Section 8.1).
- Receive all available options, including those outside the insurer's contracted network, and decide whether to pay out of network (CDA Section 9).
A general dentist should not make the patient's continued care conditional on using a particular specialist. If the dentist, or an immediate family member, has a significant beneficial interest in the organization receiving the referral, B&P § 654.2 requires written disclosure to the patient, or a conspicuous posted sign, and advice that the patient may choose any provider. The CDA Code (Section 11) likewise treats undisclosed fee arrangements as unethical.
Second opinions
A dentist giving a second opinion, for example at an insurer's request, should follow the Code and not have a vested interest in the recommendation (ADA Advisory Opinion 2.B.1). The second-opinion dentist should not solicit the patient for treatment or disparage the treating dentist without justification (ADA 4.C).
Gifts and compensation for referrals (K2073)
The receiving side is covered as much as the giving side:
- B&P § 650(a) covers the "offer, delivery, receipt, or acceptance" of any consideration as compensation or inducement for referrals. A general dentist who accepts per-referral cash, gift cards, or vacations commits the same offense as the specialist who pays.
- B&P § 1680(g) makes "accepting or receiving any commission or the rebating" of fees unprofessional conduct.
- ADA 4.E: "Dentists shall not accept or tender 'rebates' or 'split fees.'"
- CDA Section 11: "Other fee arrangements between dentists or other persons or entities of the healing arts which are not disclosed to the patient are unethical."
How to evaluate gifts:
| Gift | Analysis |
|---|---|
| A per-referral payment, or a gift scaled to referral volume | Prohibited: compensation for referrals |
| An expensive dinner or trip given to top referrers | High risk; its purpose is to induce referrals |
| A continuing education lecture a specialist offers to all local dentists | Generally acceptable professional education, not tied to referrals |
| A modest holiday card or small token sent to colleagues regardless of referrals | Low risk, but judge by intent and value |
The question to ask: would the gift influence where you send patients, or would a patient think it does? If so, decline it.
A referral communication checklist
| Step | Who | Content |
|---|---|---|
| Referral letter | Referring dentist | Reason for referral, specific question, medical history and medications, recent radiographs, patient's insurance and preferences |
| Consultation report | Specialist | Findings, diagnosis, proposed treatment and alternatives discussed with the patient |
| Treatment report | Specialist | What was done, complications, restorative timing, and when the patient should return to the referring dentist |
| Follow-up | Referring dentist | Confirms the patient returned, completes restorative care, and updates the chart |
Each step can be shared without a separate authorization because it is disclosure between providers for treatment (Civil Code § 56.10(c)(1)), though sensitive information still calls for care (ADA Advisory Opinion 1.B.2).
Worked scenario
A periodontist places implants for a patient referred by Dr. Rivera, then offers to do the patient's crowns and cleanings "so she won't have to travel." The patient did not ask for this.
- Unethical steering: ADA 2.B requires returning the patient to the referring dentist unless the patient expressly prefers otherwise. The periodontist should send a report to Dr. Rivera and tell the patient her restorative care continues there.
- If the patient herself asks to transfer her general care, she may, and the periodontist should coordinate with Dr. Rivera, including records.
An endodontist finishes root canal treatment on a patient referred by a general dentist. Under ADA Section 2.B, what should happen next?
Place the final crown, because the endodontist has the most recent information
Keep the patient for recall visits so the tooth can be monitored
Refer the patient to a prosthodontist without telling the referring dentist
Return the patient to the referring dentist for the final restoration and future care, unless the patient expressly prefers otherwise
A specialist sends a general dentist a $500 spa certificate after every fifth referral. Which statement is correct?
Both the specialist offering it and the general dentist accepting it violate B&P § 650's ban on consideration for referrals
Only the specialist violates the law, because offering is prohibited but accepting is not
It is lawful if the certificates are not cash
It is lawful if the general dentist tells patients about the arrangement
A patient referred to an oral surgeon for a third-molar consultation asks to be treated by a different oral surgeon who is closer to home. What is the ethical response?
Insist she see the original surgeon to keep the referral relationship intact
Respect the patient's choice and help transfer the referral information to the surgeon she prefers
Refuse to refer her anywhere unless she accepts the original surgeon
Complete the extraction yourself to avoid the dispute
Sections you finish are checked off in the contents.