Leading ACO Reduces Out-of-Network Referrals – Increasing Revenue By $100M Annually

Helping A Leading ACO Keep Referrals In Network

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

A top-performing physician-led accountable care organization with more than 900 practitioners knew 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
  • Providers were losing an estimated $200 million in specialty revenues annuallyExecutives knew that to turn the tide, they needed to track and manage referrals across the ACO. But to do so, they needed to solve a vital technology challenge. Their providers were using almost 60 different types of EHRs.

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


Solution: Using PH Exchange to retain and manage referrals across incompatible EHRs

After evaluating several alternatives, they adopted PH Exchange as their referral management solution. Now members can share information quickly 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 data to be imported and exported to a practice’s EHR platform.


Results: Reduced out-of-network referrals loss by 50%, increasing revenue by $100M annually

The ACO realized an immediate boost in in-network referrals as soon as PH Exchange went live. The results have been easy to document using built-in reporting tools. Since implementation, over 325,000 referrals have been sent through the platform, keeping a network leakage rate of 10% or less yearly. Using the PH Exchange solution, the ACO decreased out-of-network referrals by 50%, increasing revenue by $100 million annually.

“PH Exchange has paid for itself many times over. It has helped us address an immediate need and realize a significant financial benefit, all while delivering better coordinated patient care.”