The increasing complexity of patient referrals in healthcare
Patient referrals are increasing in number every day. Health Systems and Hospitals which send out numerous medical referrals find it difficult to track and close a patient referral loop on time. What factors prevent the referral coordinators, operations managers, physicians or care providers from closing the patients’ referral loops?
Prior Authorization – The referral coordinator does the insurance pre-authorization for the patient referrals in healthcare. Considering that one out of every three patients is referred to a specialist, it is difficult to do prior authorization. This makes patient referral system time-consuming and affects referral loop closure.
Finding the right specialist/imaging center – The referring provider must choose the right specialist or imaging center that will suit the patient best. He/She should send the referral to a reliable provider who will give the best care and give regular updates. The referring provider must also consider a provider who covers the patient’s insurance before initiating the referral. If the referring provider fails to do this, open patient referral loop becomes imminent.
No updates on the referral progress – The receiving provider fails to update the progress of the referral. 25% to 50% of referring physicians do not know if their patients actually visit the specialist or imaging center. As many patient referrals are initiated on a daily basis, tracking it manually is difficult for the referring provider. This ultimately results in open patient referral loop.
Inadequate referral information – The receiving providers usually have a tough time processing referrals with incomplete information. 70% of the specialists rate the patient referral information from the referring providers as poor. This affects the patient referral lifecycle.
Outdated referral workflow – The current referral workflow is outdated. The providers find it difficult to cope up with the increasing patient referrals in healthcare. On an average, a referring provider spends half an hour to one hour per referral and even more time in following up. Outdated referral technology affects the referral loop closure.
Close a referral loop in healthcare with the HealthViewX Patient Referral System
Information Technology enables patient referral workflow automation. HealthViewX Patient Referral Management System simplifies the process and closes the referral loop on time.
The Primary Care Provider (PCP) identifies the need for a referral and initiates the same through the EHR system.
The referral coordination team then validates the referral and does the insurance pre-authorization with the help of HealthViewX solution.
The Intelligent Provider Smart Search feature of HealthViewX Patient Referral Management System helps in finding the right specialist or imaging center easily.
The referral coordination team then sends the referral with the necessary documents to the relevant specialist or imaging center through the HealthViewX platform.
The receiving provider gets notified about the referral and can schedule appointments with the patient.
The patient and the receiving provider get reminders of the appointments thus reducing no-show rates.
The referring provider is also notified about the status of the referral and how it is progressing. HealthViewX timeline view makes tracking and managing the referral lifecycle easier.
HealthViewX tracks and sends reminders to the receiving provider to update the diagnosis, treatment recommendations, care plans in the referral.
HealthViewX makes it easy for the referring provider by automatically updating this information back to the EHR system.
Thus the HealthViewX solution closes the referral loop on time and helps in easy monitoring of the same.
Features and Functionalities
Referral workflow automation reduces the time and manual effort spent on a referral. Thus HealthViewX solution improves the efficiency of the process.
Patient coordination framework achieved through the patient application that helps in managing appointments and log data for the care plans prescribed by the provider.
Automated insurance pre-authorization reduces the work of the referral coordination team and makes the process simple.
Intelligent Provider Search feature helps in finding the right specialist or imaging center in no time.
Referral timeline view and communication enables easy flow of information between the referring and the receiving ends.
Scheduler integration gives timely reminders and notifications to the patients and the providers about appointments, lab tests, etc.
Referral insights and analytics gives the PCPs concrete data of how many referrals were converted to an appointment by a specialty care or an imaging center. It will help in analyzing who responds quickly and to whom the PCP can direct future referrals.
Benefits of closing the patient referral loop in the healthcare industry
Increased Medicare reimbursements – Medicare considers closing medical referral loop as a benchmark for giving reimbursements. Closed medical referral loops increase the opportunities for Medicare reimbursements for referral marketing.
Streamline referral management – With HealthViewX Patient Referral System in place, the referral workflow is automated and streamlined.
Improved patient care – Reduced waiting time gives patient satisfaction thereby improving the care quality.
Increased productivity – Reduced operational time improves the efficiency of the patient referral system.
HealthViewX Patient Referral Management application helps in closing the referral loop and increases the revenue for the practice. To know more about HealthViewX solution, schedule a demo with us. Our patient referral management experts will guide you through our HIPAA-compliant solution.
In the year 2011, the Center for Medicare and Medicaid Services (CMS) introduced the Annual Wellness Visit (AWV). An AWV is a yearly appointment of the patient with the physician funded by the American Affordable Care Act. It is very different from an Annual Physical Exam and is more of an educational visit than a diagnostic one. During this visit, the physician formulates a preventive plan for the patient for the coming year. This plan can help in preventing illness based on current health and risk factors.
Medicare provides Personalized Prevention Plan Services (PPPS) under the wellness plan for beneficiaries who:
Are no longer within 12 months after the effective date of their first Medicare Part B coverage period
Have not received an Initial Preventive Physical Examination (IPPE) or Medicare yearly wellness visitwithin the past 12 months
The following medical practitioners are eligible for providing Medicare yearly wellness visit services to patients:
Physician (a doctor of medicine or osteopathy)
Qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist)
Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioners), or a team of medical professionals who are directly supervised by a physician (doctor of medicine or osteopathy)
Medicare Wellness checklist
Initial Annual Wellness Visit – This is applicable the first time a beneficiary receives an Annual Wellness Visit. It includes the following components:
Acquire Beneficiary Information:The physician assesses the health risk factors of the patient. It includes analyzing patient self-reported information, demographic data, daily activities, etc. He/She collects data from the list of physicians who regularly treat the patient. The physician reviews the beneficiary’s medical and social history, completely studies the patient’s potential risk factors, mood disorders, functional ability and level of safety.
Begin Assessment:The physician begins the assessment by measuring the patient’s vitals. He/She identifies the patient’s illness through direct observation, medical history, concerns raised by family members, friends, caretakers, etc.
Counsel Beneficiary Action: The physician establishes a written screening schedule for the beneficiary, such as an appropriate checklist for the next 5 to 10 years, etc. He/She furnishes personalized health advice to the beneficiary and generates appropriate referrals to specialist clinics or imaging centers. The physician gives advance care planning at the discretion of the beneficiary.
The subsequent Medicare yearly wellness visits include the above components and will be updated on the later patient visits.
Billing Codes for Medicare Yearly Wellness Visit
Annual wellness visit which includes a personalized prevention plan of service (PPS) and the first visit
Annual wellness visit which includes a personalized prevention plan of service (PPS) and the subsequent visits
Tips for physicians to benefit from Annual Wellness Visit
Managing patients – All Medicare Part B patients are eligible for Wellness Plan services. It is necessary for the practice to find the right patients who would benefit from this service. The physicians must give the patients a clear idea of how Medicare Wellness Program process works, what they can expect from the service, etc. The practice must make the patients aware of the reimbursements and the additional charges they may incur depending on their insurance coverage.
Developing protocols for schedules – A Medicare Wellness Program takes a great deal of both staff and physician resources to give the service. It is better for a practice to take some time to decide how these appointments best fit into their existing schedule. Creating a scheduling protocol will save more time and frustration. For example, how many days in a week, the practice can schedule these appointments, what tool for tracking the Medicare Wellness Program services, patient records, reimbursement rates, etc.
Pre-visit planning – The practice must verify not only the patient’s Medicare Part B effective date but also whether the patient has received a Wellness Plan from any physician in the last 11 months. Otherwise, Medicare may deny the service, leaving the patient with an unexpected bill. The practice must do the same verification for other preventive services that patients receive along with the Medicare Yearly Wellness Visit. It is ideal to have the staff note the last date of these preventive services on a Medicare Yearly Wellness Visit documentation form in advance of the visit. This will help in determining which preventive services are needed and whether the patient is eligible to have these paid for by Medicare. A pre-visit history can also find whether the patient needs any laboratory tests such as the cardiovascular scans, diabetes screening blood tests, etc. These should be completed prior to the Medicare Yearly Wellness Visit to allow discussion of its results at the visit.
Planning for effective follow-up care – The physician should analyze the patient’s risk factors and problems accurately during the Medicare Wellness Program. The physician must generate a care plan for the patient considering these factors. It is necessary to develop a preventive service plan and a general checklist for the next ten years. The physicians should follow-up the same on the patient’s subsequent Medicare Yearly Wellness Visits.
Getting complete reimbursements – The last step in providing the Medicare Yearly Wellness Program is to get paid the service rendered. AWV attracts the physicians’ attention because of the reimbursements offered by Medicare. The practice must keep up a clear documentation to make the process hassle-free.
These practices simplify the Medicare Wellness Program process thereby improving the efficiency of the practice. The HealthViewX solution eases the AWV workflow for the practice. With HealthViewX solution, there is no chance of losing the reimbursements. To know more about HealthViewX solution, schedule a demo with us.
Hospitals in the USA play a vital role in the healthcare industry. But in today’s economy hospitals in USA are facing a serious financial crisis despite the various revenue sources. This is due to the increase in the number of uninsured peopleseeking medical services, lower reimbursement rates from the Center for Medicare and Medicaid Services (CMS), staff shortage, etc. Many hospitals are facing bankruptcy and some are eventually shutting down.
Why are hospitals in the USA facing economic recession?
The following are the few reasons why hospitals are facing financial difficulties
Lower reimbursement rates – Financial burden on the hospitals have increased due to the falling reimbursement rates from the CMS. According to the study done by the American Health Association, there is a steady decrease in the reimbursement rates for Medicare and Medicaid services. When the cost incurred on the service is more than the reimbursement received, the hospital suffers a huge loss. Hospitals in the USA received only 87 cents for every dollar spent on Medicare patients in 2016. Hospitals in the USA received only 88 cents for every dollar spent on Medicaid patients in 2016. In 2016, 66% of hospitals received less Medicare payments, while 61% of hospitals received less Medicaid payments. With the increase in the aging population, Medicare and Medicaid services will become a financial burden for the hospitals.
Increasing the number of uninsured and older people – The increasing number of uninsured and older people implies that many hospital services will go unpaid affecting their medical billing cycle. This increases the hospitals’ debt, as the state and federal laws insist on providing care for all regardless of their financial ability affecting the overall healthcare revenue cycle. In addition to the increasing number of the uninsured population, people are living longer. Therefore, they need more care and longer hospital stays.
Rising cost of hospital equipment – Hospitals must have updated equipment to retain their patients. When hospitals change to new technology they incur significant cost on the equipment and on training their staff in operating the new device. There is no more long hospital stay because of the technological advancements. This affects the medical billing revenue cycle. Also, there is an increase in labor costs due to the acute shortage of registered nurses.
Top seven approaches to maximize profitability
Industry experts say that the key to maximizing a hospital’s profit is to cut down the costs and increase the reimbursements. Following are the top seven practices that a hospital can take up amid the poor economic conditions.
Cut down staffing costs by data-driven decisions
Cut down costs by managing vendors
Involve physicians in cost-cutting efforts
Partnering with other organizations
Partnering with local physicians
Attracting new physicians
Changing the quality of service
Let us look into each of them in detail.
Cut down staffing costs by data-driven decisions – Labor is the biggest cost for hospitals. It is important for the hospitals to have the right headcount in their facilities. Hospitals can employ staff on a part-time or hourly basis. This is called “flexible staffing”. The hospitals can adjust the staff strength based on the patient census data. The hospital management must also monitor the efficiency of the staff. They can review the average hours spent on a case and compare it with the benchmark value. The hospital must communicate about the efficient staffing benchmark throughout the organization. The hospital management must collaborate with the physicians, nurse practitioners, etc to meet the expectations. Hospitals must not have a blanket approach to layoffs. The hospital management must take a close look at their business before laying off employees.
Cut down costs by managing vendors – Hospitals can cut down supply costs by working with vendors. This will improve contracts and encourage physicians to take fiscally responsible supply decisions. The hospital management should not shy away from approaching vendors for discounts. Hospitals must have only the required number of vendors. The hospitals can also ask the vendors to submit purchase orders for equipment or implants that were not included in the written agreement with the facility.
Involve physicians in cost-cutting efforts – Hospitals should encourage physicians to keep a watch over the supply costs and other activities, such as unnecessary tests and inefficient treatments that may drive up the hospital costs. The hospital must support the use of products from vendors that are cost-effective but still of high quality, especially in areas such as orthopedic implants, which can be considerably costly for hospitals. In addition, experts say the use of protocol-based care can cut down costs associated with unnecessary tests or treatments.
Partnering with other organizations – During tough economic times, some hospitals can outsource or partner with other organizations for certain services, such as food and laundry services, clinical services, etc. By outsourcing certain services to more efficient providers, hospitals can share the savings with the service provider. However, hospitals must be sure to select truly efficient providers. Often, hospitals outsource services such as laundry, food and nutrition, information technology or human resources as they do not have the capital to invest in these. Some hospitals have also begun to outsource clinical services such as emergency room staffing, anesthesiology, etc to become more efficient.
Partnering with local physicians–Hospitals can join hands with local physicians and surgery center management companies to offer outpatient services. This reduces competition and also improves the hospital’s revenue cycle management.
Attracting new physicians– Identifying and attracting new physicians to bring cases to the hospital is another way to increase profits. Physician-owned hospitals can bring in more physicians as partners, while other types of facilities can recruit new physicians who are willing to visit patients at their hospitals.
Changing the quality of service – Hospitals can change or increase the quality of services they offer to be able to compete in the market. For instance, a hospital can invest money to develop their cardiac or cancer treatment centers which will attract more patients from different areas. New programs and treatment centers will also influence more doctors and nurses to join their hospitals. This may cost a lot but it has the potential to bring in higher profits because specialized care cost more money and attracts more patients who otherwise cannot receive this care in other hospitals.
Hospitals that focus on enacting these best practices are likely to see improvements in their profitability. Hospitals can also benefit from using today’s economic conditions as an opportunity to improve their overarching approach to business, creating a more sustainable organization in the future. Schedule a demo with us to know more!
A Community Healthcare Center (CHC) is a non-profitable, consumer-directed healthcare organization. CHC serves the underserved, underinsured and uninsured people, and provides them with access to high quality and preventive medical health care. Since 1965 Community Health Systems have provided comprehensive health and wellness support services to more than 22 million Americans, who otherwise would not have had access to quality care.
Community Healthcare Network receives funds through federal and local grants and payments from patients and insurance companies. CHCs must compete once every three years for federal grant funding and use these federal grant dollars to help patients pay for their healthcare costs.
Patient Referral Management in Community Clinics
Community Health Centers comprises of PCPs who offer primary health care services and related services to residents of a defined geographic area that is medically underserved. Many patients visit a PCP in a day. Community Health Centers do not have the facilities for giving specialized treatments or for taking advanced tests. So, when a patient requires any of these, the PCP refers him/her to the most suitable imaging center or specialty practice.
Community Health Systems mostly refer their patients out of the network. The referral workflow from the perspective of a referring provider is as follows.
The PCP sends the referral through the EHR/EMR to the referral coordination team.
The referral coördinator will study the patient demographics and understand the required diagnosis.
The team coordinates for insurance preauthorization to cover the medical expenses for the required treatment/services.
Based on these, the referral coordinator will find the right specialist or imaging center for further diagnosis.
After finding the right specialist or imaging center, the patient details are sent out as a referral.
Community Health Systems sends referrals through various sources like phone, fax, email, etc.
The referral coordinator chooses the source depending on the receiving provider’s convenience.
The gap between the community healthcare and specialty care
A referral process may become inefficient and ineffective if the community health systems and the specialty clinics/imaging centers fail to communicate. When there is no proper communication from the specialty centers/imaging centers the community healthcare network finds it difficult to understand the progress of the referral. Let us see it from different perspectives to understand why there is a communication gap.
From a referring provider’s perspective, the referral coordinator receives and processes many referrals every day. After sending out a referral, it is very difficult to follow-up with it manually. There are no effective and secure means of communication between the referring and the receiving providers. If the receiving provider or the patient fails to update the progress of a referral to the referring provider, he/she will never get to know what happened with the referral. Closing the referral loop becomes nearly impossible in this case.
From a receiving provider’s perspective, the referral he/she receives may contain incomplete information. Without vital details, processing the referral will be difficult. The source of referral are many but there is no single interface to manage it all. Missing out on referrals is common. There is no way of getting a consolidated data on the number of referrals missed and the number processed. Patient referral leakage becomes imminent if the referrals remain unprocessed for a long time.
From a patient’s perspective, he/she is referred to take tests in an imaging center and then meet a specialist to continue with the treatment. If the patient has to communicate back and forth between the referring and the receiving providers for incomplete information, history of illness, etc, it annoys the patient. It is frustrating for the patient to communicate between the two ends.
Referrals become incomplete, inefficient and ineffective when the participants fail to communicate and share timely information.
Guidelines to bridge the gap between Community Health Systems and Specialist Clinics/ Imaging Centers
The referring provider must understand the reason for the referral. The referring provider should also make the patient understand why a referral is necessary and what the patient can expect from the referral visit. Give time for questions and encourage the patient to clarify their doubts during the referral appointment.
When the referral coordinator does the insurance pre-authorization, he/she must make sure that the receiving provider covers the insurance policy of the patient. This will keep the patient better informed of how much the service will cost.
It is better for the referral coordinator to contact the specialist directly. He/She can give information about the patient’s current situation, as well as other medical records, test results, and documents to avoid duplication of effort.
Both the sides have to agree on the urgency of the referral and discuss the duration of the process, frequency of referral updates and the mode of communication.
Any tool that can give prompt reminders on the appointments, follow-ups to both the patient and the receiving providers can help.
After the referral reports arrive, the provider must check the results and recommendations. If the referring provider cannot understand the specialist’s evaluation, he should contact the specialist to understand the diagnosis better.
Referral is an important part of patient care but the patients are not obligated to follow-up with the specialist. If the referral isn’t completed, the referring provider must talk to the patient during the next visit to find out why. Documenting this can help in directing future referrals to the right specialist or imaging center.