We are working on measure 374, closing the referral loop.  We are a specialty practice with many patients with HMO, Medicare Replacements, and Medicaid insurance, where the insurance carrier requires that any referral to another provider be created by the patient's primary care provider.  If we tried to refer directly, the insurance carrier would refuse it.

For this measure, do we count all of the patients who we recommended see another specialist, or do we exclude the patients who we are not allowed to send a referral? The specialist's office would be sending the report back to the primary care from whom they received the referral - they would often not even know we were involved.