Referral Management in a Nutshell

Q: What is referral management?

A: Referral management is the process of a primary care provider (PCP) referring a patient to a specialty care provider (specialist).  There are two routes that a patient could take to see a specialist.

First, the patient books the appointment directly with the specialist. For example, Joe Camel wakes up one morning and decides he should see a pulmonologist because his lungs hurt, so he goes online to find and schedule an appointment with a pulmonologist. Second, a PCP refers the patient to a specialist.  For example, during an annual check-up, Joe Camel’s PCP fears that his two packs per day may have caused permanent lung damage, so the PCP refers Mr. Camel to a pulmonologist. On average, a PCP makes 1,000 specialist referrals per year and each PCP controls $10 million in downstream healthcare spend, which is driven by referrals.

Q: Why is referral management important?

A: Referral management can save billions of dollars of unnecessary healthcare spend. Half of all specialist referrals don’t result in a visit. That’s 24 million missed specialist visits per year and these forgone care opportunities result in $150 billion of unnecessary healthcare spend annually. Missed preventive care appointments cause diseases to advance and more patients end up in the emergency room, which places unnecessary financial strain on the healthcare system. Referral management can save billions in unnecessary spend through increasing preventive care compliance; reducing the duplication of tests and treatments; reducing administrative burden; and keeping patients in network seeing the highest quality, lowest cost providers.

Q: Why do half of all patient referrals not result in a visit?

A: The burden of finding and scheduling a specialist appointment rests with the patient. For example, Joe Camel’s PCP tells him he needs to see a pulmonologist. At best, the PCP will give Mr. Camel a list of a few doctors to call. More likely, the PCP will just send Mr. Camel on his way and hope that he makes himself an appointment. Either way, Mr. Camel needs to find a pulmonologist that has the right subspecialty, takes his insurance, and has availability. There are many consumer tools, such as Zocdoc, to help Joe find a specialist, but as a result of the extra work required by the patient, there is a 50% chance that Mr. Camel forgets, gives up or decides that he feels too healthy to go see another doctor. Not only are half of referrals visits missed, but the PCP is in the dark about what happened with their patient.  In other words, it is extremely difficult to coordinate care among providers.

Q: Why is referral management difficult?

A: Referral management is a two-sided marketplace and providers have different EMR systems. To implement effective referral management, both the PCPs and the specialists must be engaged on a single system and this system must be able to communicate across electronic medical record systems (EMRs).

Q: Is there an easy referral management solution?

A: Yes, ReferWell. 

Q: What is ReferWell and how does it help improve referral management?

A: ReferWell is a cloud-based, EMR agnostic, provider-to-provider referral management solution. ReferWell improves referral management in two primary ways. First, ReferWell takes the onus of scheduling a specialist appointment off of the patient and puts that responsibility into the hands of the provider.  Moreover, ReferWell allows the PCP to directly book the specialist appointment on behalf of the patient at the point of care. This increases patient compliance by more than 60 percent! Second, ReferWell allows providers to easily upload clinical notes, irrespective of the provider’s EMR system, which increases care coordination (the specialist receives information about the patient and the reason for the visit) and allows the specialist to “close the loop” (updating the PCP on the results of the consult). With ReferWell, specialists close the loop more than twice as often!

Q: Who does referral management benefit?

A: Everyone — patients, PCPs, specialists, provider networks and payer networks. The patient experience is improved as he/she now leaves the PCP with an already-booked appointment at the right provider. PCPs can better coordinate care and track their patient through the healthcare system. Specialists increase their referral capture, reduce the admin burden for their staff and receive clinical notes from the PCP. Provider networks can track where their referrals are coming from/going to, reduce leakage from their network and increase reimbursement rates through improved performance metrics and patient satisfaction scores.  Payer networks reduce costs by increasing preventative care compliance, keeping patients in network and directing patients to the most effective providers.

Referral management is the rarely seen win-win-win-win-win!

Written by ReferWell

ReferWell is a New York-area digital health company that leverages the referable moment — the point in time when a person is most ready to take action to improve their health — to improve access to care, increase health plans’ quality performance and reduce the total cost of care while improving the members’ experience and outcomes. ReferWell’s intuitive technology platform and skilled service team helps health plans and providers manage value and help more people get on, and stay on, their healthcare journey by providing an optimized provider search, making it easy to schedule appointments at the point of care to increase patient compliance, and providing a service component to ensure providers close the loop regardless of the EMR they use.

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