Understanding the healthcare referrals process

Understanding the healthcare referrals process well will help you market your practice and grow faster than your competition. Learn how now.

Understand the healthcare referral process well. If you are a referral coordinator – This will help you be better at your job. If you’re a physician liaison – this will help you manage referring partner relationships better. If you’re a healthcare marketer – this will help you make your quota.

What are physician referrals?

We are all patients and see various specialists (e.g. cardiologists, ENT doctor) and also our primary care physician (general practitioner, PCP). When the provider diagnoses or suspects that a patient of theirs needs further diagnosis from a specialist physician, they refer the patient.

How is a physician referral made?

When one doctor refers a patient to another doctor, here’s how they do it:
– tell the patient to see a specialist of the patient’s choosing. This usually happens in the referring provider does not have an established relationship with the specialist.
– If the referring provider already knows of a specialist that they have had good experience with, tell the patient to see that particular specialist.if the referring provider already knows of a specialist that they have had good experience with, tell the patient to see that particular specialist.

The referring provider can send the report patient via a couple of ways:
– Write the referral on a notepad or a piece of paper and hand it to the patient.
– write the referral on a referral pad that the specialist might have provided the referring providers office.
– Send the referral to the referred specialist using a third party referral software.
– call the referred specialist office to make an appointment for the patient.
– Send a referral instruction to the referred specialist via fax.
– Send a referral order to the referral specialist directly from their EMR. When the referral order goes from the EMR, it can reach the referred specialist either via DIRECT email communication (EMR to EMR email) or fax from the EMR.

“Notepad” physician referrals – how do these work?

The referring doctor or doctor’s staff writes down the name and number of the referred doctor on a notepad or piece of paper and gives it to the patient. 

In this case, the referring doctor knows that they referred the patient but the referred to doctor doesn’t know that they were sent a referral.

It is up to the patient to call the doctor they were referred to and make an appointment.

Research has shown that 50+ % patients do not call to make that appointment.

How are healthcare referrals via “Referral Pad” handled?

Many doctors advertise themselves to other doctors in their neighborhood. When they advertise, they leave their referral pad with these doctors.

Here, the referring doctor or doctor’s staff writes down the name and number of the other doctor on the referred to doctor’s referral pad and gives it to the patient.
 
In this case, the referring doctor knows that they referred the patient but the referred to doctor doesn’t know that they were sent a referral.

It is up to the patient to call the doctor they were referred to and make an appointment.

Research has shown that 50+ % patients do not call to make that appointment

Phone call from referring provider to specialist office

Referring doctor office staff calls the specialist / referred to doctor office to get an appointment for their patient.

If they connect with the staff at the referred to doc’s office, they try to set an appointment for the patient (rarely happens) ASAP. 

Typically, If they don’t connect, they leave a voicemail with the referred to doc’s office AND write down this referred to doc info for patient and ask them to call the doc’s office themselves.

In this case, the referring doctor knows that they referred the patient. The referred to doctor also knows that they were sent a referral.

What happens when a patient referral is faxed over?

In this case, the doctor or doctor’s staff writes down the name and number of the patient, some more patient related information and sends a fax to the referred to doctor. They tell the patient that the referred to doctor’s office will call the patient to set up an appointment. 

Here, the referring doctor knows that they referred the patient. The referred to doctor also knows that they were sent a referral.

How about referrals sent using a physician referral software?

In this case, the doctor or doctor’s staff uses a product (e.g. referwell.com,  getreferralmd.com, mdreferralpro.com, www.smartmd.com, jointhenetwork.com, Werq.com etc) to send the referral to referred to doctor. This works when the referred to doctor is also using this software. Otherwise, the sSpecialist office gets a fax or an email that they have a referral. The specialist office that needs to provide a code from the fax or the email to retrieve the referral.

The referring provider staff enter the name and number of the patient, some more patient related information and send the referral to the referred to doctor. They tell the patient that the referred to doctor’s office will call the patient to set up an appointment. 

In this case, the referring doctor knows that they referred the patient. The referred to doctor also knows that they were sent a referral.

What information do referring providers need to send you a referral?

The very first thing that the referring provider office will check is the patient’s insurance. This is important because the insurance companies want to make sure that the referral is clinically needed.

Each plan from each payer might have specific referral requirements. This is why the referring provider office sometimes requires additional time to determine which specialist would be an appropriate fit for the patient to be referred to.

While referring providers office’s staff determines the insurance plan fit, they also find out whether an authorization is required for the referral or not.

If a prior authorization is required the referral center will submit an authorization request for the referral. This, sometimes, can take up to 14 days.

How about specialist office approval?

Just because the referral is submitted to a specialist office, does not mean that the specialist office has accepted the referral. Many times specialist providers have a referral process of their own.

Many a time the specialist provider office will ask for supporting documentation for the referral to determine its clinical necessity. The supporting documentation may include the patient record ( CCDA) and possibly supporting reports (lab reports, x-rays etc.)

Sometimes the specialist office will require the patient to take some additional tests. These tests might require prior authorization from the patient’s insurance.

Is a referring provider required to make a referral?

Ethically – yes. Technically – not quite.

Most referring providers will, however, make a referral due to their HEDIS/ MIPS related concerns.

Referral management and HEDIS

Understand this part and the relationship between physician referrals and HEDIS measures. This will help you understand why referring providers behave the way they do and how you can keep them happy.

HEDIS makes it possible to compare the performance of health plans on an “apples-to-apples” basis.

Data is reported to NCQA every June of the reporting year (e.g. June 2019) but that report is for the prior year ( eg 2018) for providers.

E.g. one of the HEDIS measures is Comprehensive Diabetes Care (CDC) – Retinal Eye Exam for patients with Diabetes type 1 or 2.

What is required to achieve good marks for this measure?

A note or letter from an ophthalmologist, optometrist, PCP or other healthcare professional indicating that an ophthalmoscopic exam was completed by an eye care professional, the date when the procedure was performed and the resultsThe primary care physician / doctor has a patient come in with diabetes types 1 or 2.

Here, the PCP notices that the patient needs a referral to an eye doctor.

They immediately refer this patient to the eye doctor (ophthalmologist).

However, they need this “note or letter” before they can claim to the healthcare payer that they met this measure and should be given high marks.

So, unless referred to doctor’s office returns the visit notes “note or letter” – the referring doctor cannot meet this measure.

What are the stages of a physician referral?

When a referring provider refers a patient to a specialist doctor using fax or referral software, the referral goes through the following referral stages.

Referral statuses:
1. Pending/Not Scheduled referral

When an appointment request (referral) is received, the referral is in “Not Scheduled” or “Pending” status.

This is called the “Request backlog” for the referral managers and referral coordinators of the referred to doctor’s office. It is their job to call and convert these patients into appointments.

Sometimes this is outsourced to a call center.

Problem –
unless someone is using a referral software to track all these referrals, or using a spreadsheet to track these (like a CRM), it is nearly impossible to manage how many referrals came in, how many are in pending status etc.
On top of this, the referring provider also wants to know “what’s the status of my referral”.. So they have to be called/emailed/faxed for updates (patient didn’t pick up the phone or patient declined to make an appointment or patient phone number is wrong or patient line was busy etc).

2. Scheduled Referral

The specialist/ Referred to doctor’s office calls patient to try and set an appointment. 

If the patient picks up the phone, the specialist office makes an appointment for the patient. This is when the referral gets to the Scheduled status.

Problem

Only 30% patients actually pick up the phone. So, if in 1 day, you get 100 referrals, only 30 patients pick up the phone.
So, the next day, you have to call 100 patients of next day + 70 patients that didn’t pick up the phone the last day.
On top of this, the referring provider also wants to know “what’s the status of my referral”.. So they have to be called/emailed/faxed for updates (scheduled).

3. Referral No Show

After a patient makes an appointment, the patient needs to be reminded to keep the appointment.. If they don’t show up, the referred to doctor would lose that time slot and won’t make money for those 15 mins (each appointment is usually 15 mins).

To make sure patients show up, the doctor’s office staff (sometimes a call center) send SMS appointment reminder to the patient 1 week before, 2-3 days before etc. This can typically be done via the EMR or PMS as well.

One challenge is that not all patient phone numbers are mobile numbers. So, appointment reminder text messages are not always delivered.

Some practices, call the patient the day before the appointment and if they cannot reach the patient, they call the patient on the day of the appointment as well.

If the patient does not show up for their appointment, this appointment/referral gets to a No Show status. 

Problem –

Every day about 10-35% of the patients do not show up. These patients are now in the “Request backlog” for the staff to call again and try to set up another appointment with them.

So, now, every day, you have to call much more than 100 patients.

Every day the patients have to be called and reminded to come in for their appointment. This also adds to the patient call/request backlog. On top of this, the referring provider also wants to know “what’s the status of my referral”.. So they have to be called/emailed/faxed for updates (no-show).

4. “Patient seenReferral status

When the patient actually shows up for the appointment, the patient referral is marked as Patient Seen.

At the end of the day or asap, the doctor that saw the patient will write up the encounter / visit / consult notes in their electronic medical record software (e.g. EPIC, eclinicalworks, Modernizing Medicine, CareCloud, Cerner, AthenaHealth, Allscripts, CureMD, GE Healthcare, Practice Fusion).

This note needs to be sent back to the referring doctor.

Problem –

Every day, if you are seeing 100 patients, you will have to send 80+ visit notes back to referring doctors (not all patients are from referrals).

Someone needs to keep track of who is sending these visit notes back to the referring providers or not.

Some people send faxes and some people mail these visit notes (postal mail) and some email them (not HIPAA secure).

Someone needs to keep track of whether mailing these visit notes or faxes is actually happening or not. This is an arduous task to keep up with using paper or spreadsheets.

How does using Referral management software help?

There are a few things to remember/understand when practices/providers are using referral software.

If the Referring doctor is using a referral software, their referral recipient partner also has to use that software (not always the case, but most of the times, this is the case). 

If the specialist office does use the software, then the referring office sends the patient referral using the software.

Few things can happen here since the referring office & the specialist office both store the patient information separately in their own separate EMRs (e.g. one could be using PracticeFusion and another could be using eClinicalWorks).

The referring office might have connected their EMR to the referral software so the patient information is automatically transferred to the referral software.

The specialist office might have connected their EMR to the referral software so the patient information is automatically transferred to the referral software.

Both of these provider offices could have connected their EMR to the referral software so the patient information is automatically transferred to the referral software, however practice 1 wants to connect their EMR to the referral software using HL7 interface and practice 2 wants to connect their EMR to the referral software using Secure Direct Messages.

Neither one of the practices might have connected their EMRs to the referral software. In this case, staff from either side has to manually transfer patient information back and forth between the referral software and their EMR (usually people forget to do these things)

Further reading