by Sean Healy...
Provider referrals management is a strategic balance of getting the best clinical outcomes while controlling overall claims cost. This starts by creating and managing a high-functioning provider and partner referral network to ensure beneficiaries and members receive the best in-network care when and where they need it.
Ensure a high-performing referral network
Referral networks should be measured on clinical outcomes, ancillary utilization, and proximity to the beneficiary or member. High-quality providers offer the lowest-cost and appropriate, high quality care. As such, claims adjusters and case managers need a way to quickly identify providers that match the beneficiary’s coverage plan to find the best specialists and ancillary providers that offer accessible appointments and locations.
Enable provider and partner referral insights
Data and analytics help to optimize referrals management by continuously assessing the referral network. Analytics data can provide claims managers and care managers with clear insights into why and when beneficiaries should be referred to a particular provider and which partner offers the most efficient and cost-effective service. Prioritization should consider price, location, rating, and outcomes to control costs while improving outcomes and satisfaction.
In addition, an intuitive referral management solution can help an organization monitor the time it takes for beneficiaries or patients to obtain an appointment or if there has been a change in the provider practice in order to expand its preferred provider network as demand increases.
Continuously check and update provider information
Accurate provider data is critical in referral management. Inaccuracies are the biggest barrier to care and contribute to higher claims costs and risk. It is essential to know if a provider moves from in-network to out of network, has moved, is no longer accepting patients, has an incorrect phone number or address before making a referral.
High performing referral networks maintain access to a centralized repository of provider data to ensure referrals to the right provider. A master provider database should be designed to check, cleanse, and manage complex, dynamic data.
Centralize referral resources
With a provider network varying in specialty, geography, and quality, it is important to keep resources consolidated and centralized in an automated, digital referrals management system. A comprehensive solution should integrate claims systems and provider directory information. Intuitive referral management solutions can even prepopulate provider and claims data to simply the workflow for claims adjusters and case managers.
A high-performing provider referral process should eliminate time-consuming administrative tasks and processes to foster better consumer and beneficiary experience and reduce the cost of care.
Learn more by checking out Perspecta's provider referral management solution.
The Centers for Medicare and Medicaid Services (CMS) is requiring that Medicare Advantage organizations, Medicaid and CHIP fee-for service (FFS) programs, Medicaid managed care plans, and CHIP managed care entities make standardized information about their provider networks available through a Provider Directory API built via FHIR.
Get to know the requirements to ensure compliance.