Referral Management in Healthcare is a hot topic. Terms like leakage, care continuity, and network integrity are tossed around with little regard for the patient being referred. Silverline believes the right approach to patient referral management is developing an Active Referral Management Program.
Let’s take a look at some alarming statistics that indicate the need for active referral management:
- 46% of faxed referrals never result in a scheduled appointment
- 55% of specialist visits are unnecessary
- There is $900k of annual leaked revenue per employed physician
- 50% of referring physicians do not know whether their patient actually sees the specialist
Developing a workflow that matches the patient with the most appropriate provider and ensures the patient and provider complete an appointment is the key to driving downstream revenue. Tracking actionable out of network referrals, allows the ACO or Provider Network to address service line and geographic network gaps. Active referral follow-up can catch out of network secondary referrals before that happens and redirect them in-network.
Most healthcare organizations participate in passive referral management:
- PCP informs a patient of the need to see a specialist or have a test/procedure completed
- Someone in PCP or Specialist office may or may not reach out to the patient
- Follow-up on referral is completed at the next PCP appointment
Active Referral Management allows centralized referral management staff to manage both provider-driven and patient-driven referral process to ensure efficient and effective management of the referral lifecycle. Successful referral management begins the moment that a provider refers a patient to a specialist or facility. Gathering the required documentation, assigning the referral to a referral coordinator and beginning the process of patient and provider/facility match as soon as possible. If it can’t be done when the patient is still in the referring provider’s office, it should be done the same day.
In my past role as the Director of a Patient Access Center for a large Colorado healthcare system, I faced a challenge common to many healthcare organizations: Create a provider directory that serves the goal of a centralized, system-wide referral navigation program. We required a robust provider directory for three key service lines:
- Community-Based Find a Provider Program
- PCP Referral Navigation
- Risk Patient Referral Navigation
The previous process was based on a manual entry of providers, clinics, and facilities in multiple systems and files, and Google Searches. In order to navigate patients to the most appropriate provider based on system alignment, geography, and specialty, we needed to create a master provider database. Despite concerns from individual hospitals, we were able to create a single provider directory in Salesforce that allowed us to both navigate patients to “in-network” providers but also track “out of network” provider usage.
The first step in creating a successful referral management program is defining and building provider and facility profiles to allow for the seamless navigation of patients throughout the system. This ensures that patients are referred within the network and all unique attributes of their journey (barriers to care, support system, care team, etc.) are shared with the team.
Communication with the patient and the receiving specialist are vital to the process. Outreach options include email and text (based on documented patient communication preferences) or a simple phone call to walk through the referral and the provider/facility matching process.
It’s important to note that many referrals to specialists are not initiated in the PCP office. Many patients self-refer to specialists. Depending on insurance coverage, a formal referral to a specialist may not be required. Leveraging the provider network and making it available to a consumer on a website or a patient via a portal or community, can make it easier to acquire and navigate patients through your healthcare system. Utilizing natural language search can help a patient or consumer find the appropriate provider for the condition or symptoms they are experiencing. This search can be backed by a telephonic nurse triage program or allow the patient/consumer to submit an online appointment request that either creates an appointment in the scheduling system or creates a follow-up case that is managed in a centralized patient engagement center.
Silverline’s Active Referral Management Accelerator
By leveraging the Salesforce platform, Silverline has created an active referral management accelerator for Health Cloud solution that allows organizations to:
- Track referral source, destination, referral destination reason, and network affiliation to identify actionable out of network referrals
- Include referral authorization, estimated revenue, and patient responsibility based on insurance verification
- Track referral status and assign follow-up tasks post-referral to determine patient satisfaction and identify secondary referral opportunities
- Utilize provider search functionality to identify specialists based on demographic or specialty attributes
- Link to Services record that includes a description, estimated revenue, patient education, and FAQ’s
Silverline can help organizations build the tools to manage your provider network, as well as, manage patient referrals, perform nurse triage, manage care gaps, manage a risk-based population, and much more. Wherever you start, Silverline has the tools and the experience to help you be successful.