Helping A Leading ACO Keep Referrals In Network

Helping A Leading ACO Keep Referrals In Network


Out-of-network referrals that decreased revenues by an estimated $200 million annually

Triad HealthCare Network (THN) is a physician-led accountable care organization with more than 900 practitioners in central North Carolina. Though the organization was thriving, its leadership team knew that it faced a significant challenge.

An analysis showed members were sending 25 to 30 percent of all specialty referrals to out-of-network providers – a move that had wide-ranging repercussions including:

  • Working with out-of-network providers was more expensive

  • Downstream diagnostics, procedures and admissions directed to more costly facilities

  • Harder to coordinate patient care

  • THN providers were losing an estimated $200 million in specialty revenues annually

Executives knew that to turn the tide, they needed to  track and manage referrals across the ACO. But to do so, they needed to solve an important technology challenge. THN providers were using almost 60 different types of EHRs.

Faxing information had become the default for issuing referrals and for sharing patient information. That made it hard to gather data, analyze patterns, and provide real-time guidance to reduce out of network leakage.

Using PH Exchange to retain and manage referrals across incompatible EHRs

A Solution To A Costly Problem- After evaluating several alternatives, THN adopted PH Exchange as its referral management solution. Now members can share information easily and securely online. PH Exchange serves as a cloud-based software that functions as an EHR companion. PH Exchange bridges the technology divide and allows information to be imported and exported to a practice’s EHR platform of choice.

A powerful user interface makes it simple to:

  • create or accept a referral

  • share documents and files of any type

  • send and receive HIPAA-compliant messages

  • organize and store information for easy retrieval

  • request follow-up details

  • generate reports, and more

Identifying In-Network Providers- With referrals managed online with PH Exchange, THN now can track and analyze referral activity and can establish important controls to keep more referrals in-network. At the time a referral is created, the originator selects a provider from a customized in-network drop down directory built into the application. It becomes simple to determine which specialists are part of THN and which aren’t.

If a referral is routed out-of-network, users are required to enter a reason code. That means THN administrators can track the number of exceptions, where they originate and why they happen in real time or on a look back basis.

“We know there are valid reasons for some referrals to be sent out of network – from patient preference to a lack of local capacity to meet urgent care demands,” says Dr. David Grapey, Specialty Medical Director at THN. “But many referrals were being sent out-of-network because of a simple lack of awareness. We now have a ready way to intervene before the referral is made.”

Improvement of over $2 million in keepage associated with adoption in just six months

Producing Breakthrough Results- THN realized an immediate boost in in-network referrals as soon as PH Exchange went live. And the results have been easy to document using built-in reporting tools. In the first six months of use, over 180 practices and 1,000 users have been on-boarded and over 51,000 referrals have gone through PH Exchange. Using the PH Exchange solution, THN has significantly decreased its out-of-network referrals and improved professional fees captured.

“We expect PH Exchange to pay for itself many times over,” says Elissa Langley, COO of THN. “It has helped us address an immediate need and realize a significant financial benefit, all while delivering better coordinated patient care.”