What Does Leakage Mean To Your Organization?

The Proficient Blog

April 15, 2020

Proficient Health

What Does Leakage Mean To Your Organization?


What Does Leakage Mean To Your Organization?

Network leakage is a real issue that exists within many Accountable Care Organizations (ACOs) around the country, and we’re breaking down the barriers to determine why patient referrals are being sent out-of-network. First, it’s important to understand what impact ACO network leakage can have. There are two areas that are hit the hardest -- patients and revenue. 

Coordinating care directly with providers in-network allows a patient’s referral, appointment, tests, results, etc. to be tracked from the minute the patient is referred. Patient’s are less likely to become frustrated by delays in care and lack of communication, ultimately enhancing the patient experience. Care coordination and patient experience are also quality measures reported to the Center for Medicare and Medicaid Services (CMS).

Out of network leakage will create major financial burdens on ACOs over time. Depending on the ACO and size, patient referrals being sent to out-of-network providers can equate to millions of dollars.  The success of an ACO’s physician network is dependent on incoming revenue, patient satisfaction, and providers improving care delivery. The upside is that in only a few short months, revenue can greatly increase if the appropriate steps are taken to decrease leakage. 

The answer here seems simple, right? Keep referrals in-network and improve care coordination & patient experience while increasing revenue. Not exactly, ACOs, even thriving ones, are facing challenges that make achieving these goals difficult. 

Many practices within the ACO  simply don’t know who their in-network providers are and choose the referral recipient based on a prior relationship or specialty search. Providing accurate, up to date visibility to in-network providers, specialties and services will improve utilization of your most valuable resources. 

Technology barriers created by multiple Electronic Health Record systems (EHRs) make it difficult to send and receive referrals, track the referral status and provide coordinated patient care. Utilizing tools that work in conjunction with each individual EHR allows ACOs to operate efficiently and without implementing one common electronic health records platform network-wide. 

Sending referrals out-of-network is inevitable for some ACOs. There are many valid reasons for sending a referral out of network - for example - lack of  a certain specialty, long appointment wait times, or just historically poor service from the in-network providers. In addition, a patient may have a preference on the provider they are referred to or a certain location which is likely out of the control of the referring provider. However, reducing out-of-network referrals from 20% to 10% can mean healthier patients and more in-network revenue.   

It’s no surprise that healthcare systems, physician offices and ACOs are now going to be affected by COVID-19 pandemic, like many others across our nation. Elective procedures have been cancelled in nearly all hospitals, causing millions of dollars in lost revenue. As doors begin to open again, it will be more important than ever to recover the revenue for sustainability, patients and employees. Keeping referrals in-network can kick-start the recovery process! 

Proficient Health helps ACOs improve patient care coordination, streamline and standardize the patient referral process, reduce referrals made to out-of-network providers and close the referral loop. Contact our team to guide you through the steps for achieving network fidelity.