I moved to a rural location and your four points are exactly how it is. I have to harass my doctor to get them to put in referrals. My wife had to go and physically walk a referral from the doctor to the hopsital across the parking lot to make sure they actually got it. Then stayed and scheduled it right then b/c getting a callback for scheduling is a crapshoot.

If the insurance corporation wants to fight about it, i would recommend forgoing letters and requests and go directly to their headquarters for the physical altercation they desire.

That's exactly what I meant, the biggest problem in the medical field is the doctors themselves, they're basically useless at this point. You could replace them with a potato and give you the same first three points of your list, but for cheaper.