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Mitigating Referral Leakage with Provider Referral Patterning

By 05.12.23
Reading time: 6 minutes

According to an industry report, 78% of healthcare services and delivery leaders say the COVID-19 pandemic, and its transition to an endemic, has made controlling patient leakage a higher priority. The continuing lag in recovery and recuperation to reach normalized pre-pandemic new patient volumes and existing patient visit frequency from their established panels — coupled with the additional headwinds of staffing shortages, supply chain disruption, new entrants into the care delivery landscape, and the increasing costs associated to deliver care — is negatively impacting financial stability, and contributing to negative EBITDA trends. 

That same report revealed that 65% of healthcare system leaders and providers confidently state that continued increases in referral leakage blocked them from reaching and achieving their strategic imperatives in 2022 and has strained the revenue streams associated with those imperatives. They also believe that this trend will continue through 2023 and mitigation strategies are an urgent need.

Yet, despite these statistics, the majority of healthcare delivery leaders and providers across all care and service silos within the industry have not been able to facilitate a consistent and centralized process-driven approach to quantify, assess, and visualize the totality of their referral volume and its patterning. They are unable to consistently identify and isolate the reason codes (both controllable and non-controllable) creating or contributing to their gross and net leakage rates without extensive effort and heavily manual process flows, and they do not have the resources to execute on this initiative with the frequency and consistency required to effectively measure, manage, and implement corrective actions to reverse the trend. 

The key to mitigation and remediation of the trend is to understand how to solve for the leakage, optimize the contributing factors driving the keepage, and how to better define the true penetration of the consumer/patient/provider market that generates the referral volumes, by type, payer mix, and condition code needed to attain the topline revenue and growth targets for their business models. 

  • Nine out of 10 healthcare executives and providers are not highly confident in their capabilities to achieve needed visibility into their referral leakage. 
  • 75% are not sure what is driving specific service line referral leakage or how to prioritize and remediate those that have been most impacted in terms of immediate volume and top line revenue losses, as well as quantify and address impacted downstream revenue from loss of those referral volumes. 
  • Moreover, they have limited visibility to identify which service lines are actually primed for natural growth given the service demand in the market they serve.

Why referral patterning is important and its influence on referral management

Provider referral patterning is an essential part of the provider referral management and provider relationship management model. Its functional approach and capability to create a centralized mapping and data visualization tool produces a 360-degree aggregation of the quality and quantity of ambulatory referrals, ancillary order sets, outpatient diagnostics order sets, and surgical scheduling order sets, reconciling them with clinical care delivery data for purposes of improving and growing the quality of the internal and independent Clinically Integrated Network (CIN). 

This model allows for an accounting of visibility to actual and trending market penetration/saturation rates, referral/order-type mix, payer mix, reason codes for gross referral/order capture/leakage and keepage, and net conversion capture/loss rates. It’s an invaluable tool to align efforts to promote growth, attribute the impact of marketing campaigns and outreach, and gain visibility into Physician Liaisons’ and Business Development Managers’ productivity and performance, provider service recovery needs and results, predictive modeling, capacity management, and alignment of supply demand modeling for care delivery against market trends. 

In addition, it also allows for the ability to incorporate a healthcare system or provider’s claims data, as well as third-party claims data, to heatmap the market and identify and execute tactics to capture referral share that is currently untapped, or competitively held. It provides visibility into pockets of a healthcare system or provider’s areas of exposure that could result in market share loss.

As the model progresses in execution, it also allows the ability to truly understand the reason codes that are creating leakage of referral volume. For example, referral volume may be impacted by access issues, a lack of closed-loop feedback to the referring provider, or referral turnaround and processing times. The patterning approach allows for attribution of the leakage to the reason codes and then yields the ability to take the needed remediation paths or implementation of best practices to curtail leakage. The model also allows for the identification of the optimal or needed paths to take or create with people, process, and technology. 

Even more valuable, this provides insight to non-controllable market conditions, allowing for the appropriate provisional action to take to offset the impact to volume from those reason codes. An example of this would be losing exclusive status with a payer that could result in loss of referral volume, and allowing for the system to quantify that risk and execute precise and aggressive retention marketing campaigns to patients/consumers with that payer coverage and their provider/care network team. 

It could also be something as simple as identifying the need for expanding hours of operation for convenience to the patient/consumer population. Or positioning the brand awareness of the quality of care and clinical outcomes provided to the market by the healthcare system or providers to retain or win back potential patients that may leave or have churned out of panel as a result of that payer status change.

How leveraging CRM for provider referral patterning helps healthcare systems and providers 

Most large healthcare systems have anywhere from 50 to 70 percent dependency on referral volume from a CIN for their total revenue streams. Yet many healthcare systems are not effectively marketing themselves as the destination point for both patients and providers.

Providers act as the catapult and the net for the patients that walk in their front doors. But healthcare systems have been latent in adopting acquisition-based strategies and governance models to effectively drive those patient volumes to their front door, especially when it comes to technology adoption. The two areas in which healthcare systems are typically not optimizing technology platforms are inside of the business development/physician liaison group and the marketing group. 

Most healthcare systems rely on a fractured provider relationship management model that does not allow them to capitalize on the benefits of a provider referral patterning model and the provider referral and provider relationship management processes and models in place. They are using outdated platforms or even spreadsheets to piecemeal the data together. This highly inefficient and time-consuming process results in a lack of 360-degree visibility for business development, clinical care delivery, and operational teams. 

By leveraging a CRM solution like Salesforce, a provider can centralize the accounts, activities, and contacts that define its CIN and the marketplace. The platform can also act as the central repository for provider referral patterning and the data visualization tool that aggregates all pertinent data types to allow for seamless reconciliation and attribution, all in an automated fashion set to the cadence preferences of the healthcare system or provider. 

The platform pulls data from the provider’s EHR and third-party data sources. It then heat maps the marketplace to identify where the referrals are coming from in terms of volume and payer mix. The platform then reconciles that information with the referral patterning that the system has seen and the overarching operational capacity in order to identify where and how referral leakage can and will occur, and quantify the impacts both in the arrears and for future state forecasting and predictive modeling. 

The platform enables providers to effectively improve the measurement, management, and optimization of their CIN volume. It acts as a repository of information, and providers can take action against that information that allows them to:

  • Target growth opportunities for new patient volume and with specific providers based on where their occupancy or capacity rates are with service lines. 
  • Identify where they may need to protect their market share by seeing potential overlaps with a competitor in the marketplace.
  • Recognize improvements to their overarching service offerings to the system and the CIN and develop new services based on referral or order patterns or expand locations or hours.

Provider referral patterning and its interoperability for provider referral and provider relationship management can all be operationally enabled by Salesforce Health Cloud paired with Salesforce Marketing Cloud. The platform can integrate seamlessly with an EHR and with any internal or external claims data sources. This allows for seamless access to specific information that validates what the referral patterning looks like in terms of what’s been captured and lost and what the market opportunity may look like. 

The data and analytics capabilities facilitate data visualization with a dashboard model that allows the user to look at overarching volumes, penetration rates, service scoring, supply-demand modeling, access and capacity validation, and heat mapping of market penetration.

The Silverline differentiator

Healthcare systems must recognize that the providers referring into the system are as much of a consumer as the patient. By implementing Salesforce to assist with referral management, providers open up market share opportunities and generate positive impacts across the continuum of care. The patients benefit from getting the referral to the right provider, with the ability to get it scheduled in the right time frame for the right service delivery and, ultimately, the right clinical outcome. 

Unlock the ability to ensure effective and efficient management of the referral lifecycle with Silverline. We provide strategy, advisory, technical implementation, and ongoing managed services to meet your current and future needs and to achieve maximum value with the Salesforce platform. Find out how we can help your healthcare organization.

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