Three ways to modernize provider referral management processes to keep patients in-network

Today, healthcare executives face challenges as they seek to navigate shifting payment models and maintain already narrow margins. The demand to increase revenue while simultaneously cutting costs is not an easy problem to solve. Referral management is one area to which organizations can look for solutions.

In a recent CHIME-Cerner survey, nearly 40% of provider participants indicated they were losing at least 10% of patient revenue to referral leakage¹. With one out of three primary care visits resulting in a referral², improving referral management can help keep revenue in-network and serve as a bridge from fee-for-service (FFS) to value-based care (VBC). However, providers often make referrals based on who they know without taking into consideration supply (provider capacity) and demand (patient needs and preferences), helping contribute to patient leakage. There is an opportunity to address this gap by embracing standardization, creating a data foundation to map consumer needs to provider availability and pivoting from retroactive analysis to real-time decision-making.

Today, referrals often depend more on personal relationships and fax machines than on the use of technology to analyze, manage and standardize the referral process. However, data plus process standardization can help drive return on investment (ROI) in both the short-term and long-term by eliminating the guesswork to guiding referrals. 

Standardizing the referrals process across your network cultivates an outcomes-first culture that emphasizes efficiency and high performance by setting consistent expectations and clear communications. Organizations should seek to standardize processes with data-driven workflows. Efficient referral practices standardize which patient data must be sent, and to whom, to provide scalable solutions that are automated when possible. Business rules built into workflows and a user-friendly interface can help support the ease of sending and receiving referrals, enhance provider-to-provider communication, and close the loop on referrals to promote high quality care delivery.

Patients are now consumers, and like in other industries, have a choice in their healthcare. It is essential to address consumer’s preferences and convenience; however, providers need data to make those decisions. To better match supply and demand, providers need visibility into the entire network. When providers make referrals based only on who they know, it limits patients’ access to other providers who may better fit their needs. It can also result in the overutilization of some providers and underutilization of others. One way to address this challenge is to use the power of data that spans multiple technologies and systems to create and maintain a centralized provider directory. Algorithms can then run against the centralized provider directory to help determine which provider is best suited for the consumer based on specialty, insurance network, patient proximity, network affiliation and clinical quality scores.

The lack of easily accessible data to visualize historical referral patterns — combined with the lack of actionable, real-time analytics to measure, manage and scale referrals — has created a systemic failure.  To make better referral decisions, providers need timely, accurate data within their existing workflows. New referral intelligence engines use algorithmic logic to determine the ideal referral based on factors such as cost, quality, accepted insurance, and location. Organizations can even configure these algorithms based on their specific needs.

While mining data to make informed referral decisions is foundational, it is not effective unless it is easily accessible. Providers are often working from automated spreadsheets at best. These become even more cumbersome when looking for in-network providers while operating in a large network. To effect referral patterns, providers and support staff need evidence-based rules that feed from the centralized provider directory at the point of care. Robust precision-based rules can guide real-time referral decisions that take into consideration data hosted in a centralized provider directory. By surfacing decision support insights in standardized workflows, your providers and support staff can proactively impact referral patterns to drive toward optimal outcomes.

Thin healthcare margins and the advancement of VBC has created an operating environment that challenges healthcare stakeholders to think differently. Referral management can help provider organizations execute FFS strategies of today, while developing capabilities necessary for the VBC strategies of tomorrow. Past referral strategies and technologies need to evolve. Technology can help reduce friction in workflows and act as a lever to support a highly-efficient, high-performing referral processes to keep patients in the networks you have worked so hard to build.

Visit cerner.com/healthereferrals to learn more about how referral management technology has evolved to meet your needs.