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Docs Could Avoid 34% of Out-of-Network Patient Referrals with Data

A lack of comprehensive provider directory data from health systems is driving 79 percent of physicians to make out-of-network patient referrals, a survey revealed.

Out-of-network referrals and patient retention

Source: Thinkstock

By Jacqueline LaPointe

- Providers recognize the importance of making in-network referrals for care coordination and patient retention. However, 79 percent of physicians still refer patients to other providers outside their health system’s network, a new survey shows.

A survey of 200 physicians affiliated with health systems across the US by Kyruus and Wakefield Research revealed a significant gap in provider behaviors and perceptions of in-network referrals.

About 84 percent of physicians reported that their health system has requirements around referring to in-network providers, and the majority of respondents (79 percent) fully or strongly agree with the requirements.

Referring patients to in-network providers is key to delivering coordinated care. Over three-quarters of physicians (77 percent) said keeping patients within the health system’s network is important for care coordination.

Despite the importance of in-network referrals, physicians oftentimes direct their patients to out-of-network doctors. Respondents estimated that they send about 22 percent of their patients to physicians not affiliated with the health system.

READ MORE: Provider Data Integrity Key to Directory Accuracy, Value-Based Care

Physicians said they are referring out-of-network primarily because patients request providers outside of the system.

But limited access to the data necessary to determine network status was another top factor preventing physicians from making in-network referrals, the survey indicated.

Only about 60 percent of physicians surveyed said they have access to a provider directory from their health system. Providers in hospital-owned practices were more likely to have access to a health system-curated provider directory (76 percent) compared to their peers in academic medical centers (33 percent) and solo private practices (44 percent).

“Without access to a single directory they can trust, providers are likely to do their own research or use external resources (e.g. insurance directories), which could lead them to suboptimal referral decisions that impair patient and provider satisfaction,” the survey report stated.

The survey also showed that providers lack access to a variety of data they feel is important for making high-quality, in-network referrals. For example, 96 percent of physicians said seeing a provider’s general specialty and subspecialty is extremely or very important to inform referrals. But just 63 percent of respondents reported having access to the information.

READ MORE: Provider Data Standardization Critical to Improving Inaccuracies

About 91 percent of physicians also identified information on a provider’s specific area of clinical focus within a subspecialty as extremely or very important. However, only 57 percent of survey participants had access to the data.

In addition to a lack of clinical data, physicians also reported limited access to scheduling information. The vast majority of physicians (93 percent) said having a provider’s availability to a see a patient in a timely manner was key to informing referral selections. But only 57 percent of physicians had access to that information.

Without comprehensive information on other providers in a health system’s network, physicians are referring their patients to the same providers. Seventy-two percent of respondents reported referring to the same provider for a given specialty most of the time.

“[W]hile referring to a specific provider may boost patient retention, it can contribute to poor network utilization if the referral does not factor in both clinical expertise and appointment availability,” the report stated. “This implies there may be missed opportunities to connect the patient with a provider with similar clinical expertise who can see the patient sooner.”

Physicians could improve their referral patterns if they had access to more information on providers in their health system’s network, respondents agreed. Over one-third of out-of-network referrals (34 percent) could be avoided with increased access to comprehensive data on in-network providers, estimated physicians who refer out-of-network.

READ MORE: What Is Healthcare Revenue Cycle Management?

Health systems should ensure their provider directories contain information that is important to physicians. Doctors are seeking more detailed clinical data, as well as information on a provider’s availability to see patients.

“The survey found that providers who reported referring out-of-network were significantly less likely to have access to availability, location, network affiliation, and insurance information than providers who never refer out of network, supporting the need to make more comprehensive information available to referring providers,” the report stated. “Without these details, research shows an over-reliance on providers within a personal network, who may or may not be the best options for a given patient.”

Improving provider directories should help physicians refer to other providers affiliated with the health system, which should improve care coordination and patient retention.

Providing referral feedback is also key to improving the rate of in-network, high-quality referrals and care coordination, the survey suggested.

Physicians reported that their health systems do not consistently confirm that a referral appointment occurred. Health systems also do not consistently tell providers of the next step in a patient’s care after the referral, respondents said.

Health systems can show providers the value of their in-network referrals by sharing key information after a patient referral. Almost three-quarters of physicians (74 percent) want health systems to share lab results after a patient referral, while 61 percent want imaging results, 55 percent want a confirmation that referring provider saw the patient, and 53 percent want to receive a specialist’s assessment and care plan.

Offering referral feedback helps to engage providers around referral patterns. Showing providers that their in-network referrals boost care coordination and patient retention encourages doctors to make similar referrals in the future.

“[T]ransparency into patient outcomes can help guide providers towards better referral behavior or enable health systems to fill gaps in their network that cause out of network referrals,” the survey report concluded.


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