Using Advanced Referral Management Tools to Impact Key Metrics- Part 2

Using Advanced Referral Management Tools to Impact Key Metrics- Part 2

In our last blog post, we took a look into understanding and identifying the operational issues that ACOs and their participating providers face. This blog will focus on a few examples of how Proficient Health is helping our customers rise to these challenges:

Achieving CMS Quality Metrics

Each provider in this ACO’s network had agreed to performance criteria that aligns with CMS and commercial payer quality metrics. In-network specialists, for example, have committed to delay-free reviews of consult requests. Unfortunately, more than 25 percent of the network’s specialty referrals were being sent to out-of-network providers with no obligation to conform to these standards. As a result, patient experience and quality of care suffered due to long wait times and delays in consult communications.

This ACO is now processing nearly 7,000 referrals a month through PH Exchange, and has significantly reduced out of network referrals.

Benefits include:

  • Better coordinated care – it is now easy to track activity and create a single patient record that carries across multiple EHRs. Messages are easily and securely exchanged between providers to coordinate care.

  • More timely appointments – referrals are streamlined and common delays are eliminated, reducing time to appointment.

  • Comprehensive quality reporting – referral metrics are now easily tracked at the network, group and practice level, simplifying performance monitoring. They can easily track the volume and source of referrals, referral status, duration between stages of the referral process, leakage rates and reasons for out-of-network referrals.

  • Network Management – by better understanding referral patterns and the reasons why providers are referring out of network the ACO management team can better understand where they might have provider quality issues, geographic and sub-specialty gaps in their network, and/or where they might need to do more practice education on the capabilities available in the network.

Driving More Revenue to In-Network Providers 

When an analysis showed another ACO that members were sending 25 to 30 percent of all specialty referrals to out-of-network providers, they realized that equated to an estimated $200 million in lost specialty revenues annually.

Thankfully, they 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, this ACO has significantly decreased its out-of-network referrals and improved the revenue capture for its in-network providers.

According to the ACO’s COO, PH Exchange is now paying for itself many times over, by helping them address an immediate need and realize a significant financial benefit, all while delivering better coordinated patient care.

Closing the Patient Care Loop 

Members of this ACO use almost 60 different EHRs, creating system-wide communication challenges. Faxing had become the default for transmitting referrals and patient information across practices, but was creating workflow issues. Nearly 70 percent of the network’s primary care providers said they were sending patient histories or the reason for the consult with their referrals, but only about a third of specialists said they received the information primary care providers sent.

This disjointed information flow also was impacting patient satisfaction, which under the proposed Direct Contracting Model (DCM) will become a much bigger driver of an ACOs’ quality score.

PH Exchange has helped the organization produce transformative changes in both care delivery and the patient experience, with seamless access to patient information across multiple EHRS and the ability to track ACO-wide standards compliance. As a result, the ACO has reduced scheduling delays and improved patient satisfaction. Thanks to PH Exchange, they now have a seamless, closed-loop workflow to support faster and better-coordinated care delivery, benefitting both patients and providers.

Contact us today at or (336) 389-6600 to explore what options we have for your organization!