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Do I need a referral for that? Focus on Referrals and Authorizations for Big Returns

Referral and Authorization workflows are vital to the financial health of your organization. They can determine if, how, and when patients are seen for services, and if you are reimbursed for those services. Due to the variety of stakeholders required, antiquated technology, and high differentiation across operations, this has historically been a challenging area to manage and optimize effectively. However, thanks to advances in technology and best practice operational models, there are significant opportunities to improve efficiency and reduce risk. 

By focusing your organization on enhancing your referrals and authorizations operating model and technology you can:

  • Reduce authorization related denials
  • Understand and control referral leakage
  • Enhance your patient experience
  • Increase staff productivity and accuracy
  • Create reporting capabilities and accountability structures for continuous improvement
  • Align your operating model to industry best practice
  • Ensure you are utilizing the latest technology

To help your organization move towards achieving these outcomes, The Wilshire Group will be publishing a series of focused posts on several of the topics below over the coming weeks:

  • Referral and Authorization Strategy– Having a strategic plan for your referral and authorization operations is central to aligning to best practices, increasing efficiency and reducing risk.  Having a big picture view of your operations and IT road map will help you invest efficiently, reduce risk, and increase ROI.
  • Referral Generation - Automating referral generation within your system and your community physicians is an important step in the referral process that can save you time and money. Taking information entered by the physician decreases manual intervention and improves time to get referrals routed to the appropriate staff. If you are utilizing automated authorization products, automated referral generation can initiate the request for approval. Increasing strategic automation in this area will increase your referral capture rate, reduced denials, and enhance reporting capabilities.
  • Authorization Requirement Analysis - To further streamline the referral process, it is important to analyze what procedures require authorization by payer so that end users can focus on those referrals that require follow up by the payer. Having standard requirements across your organization will increase referral throughput, increase staff productivity, and enhance reporting capabilities.
  • Referral Accountability and Reporting Structure - Develop a process from order initiation all the way through authorization and the subsequent referral visit so that ownership and communication is clear through all points. This includes workqueue review, standardized referral templates, management consulting, reporting, letters and other processes. Implementing a reporting and accountability structure lays the foundation for your organization to continuously improve, promote transparency, and drive productivity.
  • Referral Pattern and Leakage Analysis – Use your EHR and payer data to identify root cause and mitigate referral leakage at your organization. By understanding where your patients are having their services performed, or not performed, empowers you to increase your referral capture rate, provides insights into physician and patient behavior, and improves the patient experience.
  • Denials and Follow Up Analysis - Develop a process for end users to manage referrals that are not authorized by the payer. By creating exception-based workflows, your staff can focus only on the referrals that require manual intervention. This process will increase your denial productivity, focus your staff on the right work, and enhance your reporting capabilities. 
  • Authorization Product Strategy and Implementation - Many vendors offer services to connect to payers electronically utilizing the ANSI 278R interface. This interface can automate the inquiry and submission processes for a referral and some vendors will also offer automation for determining what requires a referral. Implementing this technology can drastically increase productivity, enhance the patient experience, and reduce your denial rate.

If you are interested in how your organization can make strides in these areas, we’d love to speak with you. Please e-mail Freeman Jenkins and Matt Perron. You can also read more about our Patient Access services at our website.