Tag Archives: healthcare

How Can Physicians Benefit From HealthViewX Chronic Care Management Solution

More than half of the U.S population is suffering from various chronic conditions. Such patients need continued care and support from their physicians. Considering the physicians’ busy schedule, they cannot extend special support to every other patient with chronic conditions. This directly affects chronic patients. Both physicians and patients face a lot of challenges in the process of giving care to chronic patients.

Care Management Workflow for Chronic Patients

Let us consider a scenario to explain the care management workflow for chronic patients.

The chronic patient gets sick – Lily is a diabetic patient who also had blood pressure. She fell down and hurt her head so severely that she started bleeding. As she was diabetic, the wound did not heal. She wants to visit Dr. Matthews who is her PCP.
PCP examines the patient – Dr. Matthews is a busy physician who runs a clinic. Lily waits for two hours to get his appointment. The doctor examines Lily along long hours of her waiting. He advises her to stay in the hospital for two days. The nurses there take good care of her by giving her medications on time, attending to her whenever in need, etc.
The patient gets discharged – After two days, Lily feels that she is all right. She is discharged from the hospital. Dr.Matthews prescribes her medications to be followed strictly to get completely well.
Patient falls ill again – Though Lily takes care of herself, the wound starts bleeding again. She tries reaching the doctor but to no avail. It was only after a day did she get his appointment again.
The patient is readmitted – Dr. Matthews examines her again. He finds that she did not take the medications appropriately. He advises her to stay in the hospital for another day.

Challenges faced by physicians

Though Dr.Matthews took good care of Lily, it could not avoid her get readmission. If only he had been more available to Lily virtually, this would not have happened. So what factors stop Matthews from being available to Lily?

Outdated technology – Dr.Matthews’ clinic has a manual appointment scheduling method. Hundreds of patients call the clinic every day and the possibility of one getting an appointment is only 10%. This prevents him from catering to patients who need immediate diagnosis and attention.
Limited resources – The availability of staff is less in number. Even if Dr.Matthews recruited new people, it would increase his operating costs significantly. The use of a new technology to manage the patient traffic is also not a great idea as it is costly.
No remote patient monitoring tool – Patient readmissions can be avoided only when Dr.Matthews gives continuous care to his patients. He does not have a remote patient monitoring tool or the staff availability to handle it. Because of this, he is finding it difficult to be available to his patients.

Chronic Care Management Program

CMS was spending a lot of money on patient’s insurance who were suffering from chronic conditions. In order to cut down the expenses on hospital admissions, the CMS introduced the Chronic Care Management (CCM) program. Through Chronic Care Management program, the physician can give more attention and care to the patient.

What is Chronic Care Management?

Medicare defines Chronic Care Management (CCM) as non-face-to-face services provided to its beneficiaries with multiple (two or more) significant chronic conditions. In addition to office visits and other face-to-face encounters (billed separately), these services include

Communication with the patient
Health professionals being available both electronically and by phone for care coordination, medication management, and being accessible to patients.

HealthViewX Chronic Care Management solution to simplify the process

Chronic Care Management program is indeed a good idea to track your patients regularly. But when done manually, it becomes another burden for the physician. This is when a Chronic Care Management software comes to play. It reduces the time and manual effort spent in giving the CCM services. Let us consider the same scenario to explain the Chronic Care Management workflow,

The chronic patient gets sick – Lily is a diabetic patient who also had blood pressure. She fell down and hurt her head so severely that she started bleeding. As she was diabetic, the wound did not heal. She wants to visit Dr. Matthews who is her PCP.
PCP examines the patient – Dr. Matthews is a busy physician who runs a clinic. As he is Lily’s PCP, she has HealthViewX application in which she can see the doctor’s availability. She fixes an appointment with the doctor in no time. Dr.Matthews examines her and advises her to stay in the hospital for two days. The nurses there take good care of her by giving her medications on time, attending to her whenever in need, etc.
The patient gets discharged – After two days, Lily feels that she is all right. She is discharged from the hospital. Dr.Matthews prescribes her a care plan with medications and exercises to be followed strictly adhered to.
The patient is continuously monitored – Lily takes care of herself by adhering to the care plan prescribed. She gets monthly calls from the CCM team. If at all she falls sick, the application will help her to reach out to the physician as soon as possible.

HealthViewX Chronic Care Management solution features

HealthViewX Chronic Care Management solution has the following features that make the process simpler for physicians and patients,

Inbuilt audio, video calling and messaging features – HealthViewX Chronic Care Management solution has inbuilt video and audio calling features. It helps in giving Chronic Care Management services to their patients. Secure messaging is also available through which the physicians and the patients can communicate.
Automated call log feature – After a call, care plan creation or any action related to CCM health services, the system automatically adds call logs. It reduces the physician’s manual effort is logging the call logs.
Preventive Care plans – HealthViewX solution supports care plans for the Chronic Care Management service for a patient. The physician can create a care plan depending on the patient’s health report. It helps in monitoring the patient’s vitals.
Chronic Care Management Analytics – Dashboards with intuitive charts and tables give complete analytics of the Chronic Care Management services. It provides a clear picture of the revenue perspective.
Consolidated Report – The physician can generate a consolidated report of the Chronic Care Management services given for a particular period. This makes it easy for the billing practitioner for getting the Medicare reimbursements.
HIPAA compliance – HealthViewX Chronic Care Management is HIPAA compliant. It facilitates secure data exchange. The solution manages all patient-related documents securely.

HealthViewX Chronic Care Management solution has features that suit the physicians best. To know more about our Chronic Care Management solution, schedule a demo with us.

Chronic Care Management Services In Federally Qualified Health Centers

What are FQHCs?

Federally Qualified Health Centers (FQHCs) in the United States are non-profit entities comprising of clinical care providers, that operate at comprehensive federal standards. The care providers in FQHC are a part of the country’s health care safety net, which is defined as a group of health centers, hospitals, and providers who are willing to provide services to the nation’s needy crowd, thus ensuring that comprehensive care is available to all, regardless of income or insurance status. FQHC is a dominant model for providing integrated primary care and public health services to low-income and underserved population. There are two types of FQHCs, one receives federal funding under Section 330 of Public Health Service Act and the other meets all requirements applicable to federally funded health centers and is supported through state and local grants. To receive federal funding, FQHCs must meet the following requirements.

Be located in a federally designated medically underserved area (MUA) or serve medically underserved populations (MUP)
Provide comprehensive primary care
Adjust charges for health services on a sliding fee schedule according to patient income
Be governed by a community board of which a majority of members are patients at the FQHC

What is Chronic Care Management?

The CMS introduced the Chronic Care Management program in 2015. It insisted care coordinators give 20 minutes of monthly non-face-to-face care management services for beneficiaries with two or more chronic conditions. It helps in managing their conditions, risk factors, medication adherence, and coordination of care with other providers. In order to claim CCM reimbursements, the practices must offer

24/7 access to care management services
a platform for direct patient-practitioner communication
ability to manage transitions between providers and settings

Chronic Care Management in FQHCs

It is not mandatory for FQHCs to furnish Chronic Care Management services for their patients. These services can be given in addition to any routine care coordination services already furnished as a part of the patient’s visit to FQHC. Though it is not mandatory for them to give CCM services, they can bill for the same if the CCM requirements are met.

The CCM billing for FQHCs is a little different though. For CCM services furnished between January 1, 2016, and December 31, 2017, FQHC can bill the under the CPT code 99490. Payment is based on the Physician Fee Schedule (PFS) national average non-facility payment rate for CPT code 99490. FQHC claims submitted using CPT code 99490 for services on or after January 1, 2018, will be denied.

For CCM services furnished on or after January 1, 2018, FQHCs can bill CCM services under the general care management HCPCS code, G0511. CMS has set the payment annually at the average of three national non-facility PFS payment rate for CPT codes 99490, 99487 and 99484.

It is important to note that the 2018 payment of HCPCS code G0511 is $62.28. It is high compared to the reimbursement of $42, CMS gives to practices other than FQHCs under the 99490 CPT code.

Why should FQHCs give CCM services to their patients?

Increased reimbursements – FQHCs receive grants for treating their patients. When they provide Chronic Care Management services to their patients, they get more grants from CMS. This increases the revenue for FQHCs.
Improved patient satisfaction – Chronic Care Management services establish a long-term connection with patients. The patients can reach out to the physicians at any time in need. This improves patient experience and the FQHC will see more patients coming into their hospital.

HealthViewX Chronic Care Management Software, the best fit for FQHCs

FQHCs are reluctant in giving CCM services to their patients as it is a laborious task. With increasing CCM requirements from CMS, FQHCs are worried about taking up the Chronic Care Management program. This is when an electronic healthcare product can come to play. HealthViewX Chronic Care Management solution has features that solve most of the problems faced by FQHCs.

Inbuilt audio, video calling and messaging features – HealthViewX Chronic Care Management solution has inbuilt video and audio calling features. It helps in giving Chronic Care Management services to their patients. Secure messaging is also available through which the physicians and the patients can communicate.
Automated call log feature – After a patient call, care plan creation or any action related to Chronic Care Management services, call logs are added to the patient. It reduces the physician’s manual effort is logging the call logs.
Preventive Care plans – HealthViewX solution supports care plans for the Chronic Care Management service for a patient. The physician can create a care plan depending on the patient’s health report. It helps in monitoring the patient’s vitals.
Chronic Care Management Analytics – Dashboards with intuitive charts and tables give complete analytics of the Chronic Care Management services. It provides a clear picture of the revenue perspective.
Consolidated Report – The physician can generate a consolidated report of the Chronic Care Management services given for a particular period. This makes it easy for the billing practitioner for getting the Medicare reimbursements.
HIPAA compliance – HealthViewX Chronic Care Management is HIPAA compliant. It facilitates secure data exchange. Our solution manages all patient-related documents securely.

HealthViewX Chronic Care Management solution is on par with the current requirements of the CCM program by the CMS. It helps FQHCs to set up a CCM program with the least investment. To know more about our Chronic Care Management solution, schedule a demo with us.

Does A Referral Management Software Really Enhance The Patient Experience?

When patients need advanced treatment or additional diagnosis that cannot be given within the practice, they are referred to a specialist/imaging center. The process of managing all the patient referrals that are received or sent is called patient referral management. There are many challenges faced by the patients in the referral process.

Challenges faced by patients

Let us review a typical referral process including the challenges faced by the patients.

Patient visits the PCP – Andrews met with an accident recently. He met his PCP, Dr. John the next day as he was experiencing pain in his knee joints. After examining him, Dr.John wanted him to consult an orthopedic. The doctor then initiated the referral.
PCP initiates the referral – John created a referral in his EMR. He did not have time to do the insurance pre-authorization so he left it to Andrews. He then found an orthopedic and gave him referral information verbally. Now when he met the specialist, Andrews had to again elaborate his condition and problems to him. This increased the efforts he took to meet a specialist. It did no go well with Andrews as he was already in pain.
Patient Disorientation – John had instructed Andrews about the specialist he should visit, tests he should take and how to explain his condition. Andrews found these instructions too complicated to comprehend. He left the clinic with lots of confusions and doubts.
Patient visits the specialist – Andrews then called the specialist a number of times. The first two times, the line was engaged. Finally, when he got through, all appointments were booked for the day. to confirm his appointment. He had to wait for 24 hours in pain to meet the specialist. He spent another two hours in coordinating with the insurance company. At last, He met the orthopedic after long hours of waiting in pain. He got treated but was not happy with the waiting time and negative experience. He did not get back to the PCP to share referral updates and plans to visit some other PCP next time.

Challenges faced by the physicians

What factors stop Dr.John from giving the best patient experience to Andrews?

Insurance Pre-authorization – John runs a practice where he treats many patients in a day. He has not adopted a referral management software. So he has to do the insurance pre-authorization for his patients. It is time-consuming and tedious.
Finding the right specialist/imaging center – The clinic has no effective approach for finding the right specialist/imaging center. The chances of missing out on a good specialist/imaging center are high as it is done manually as they are not updated regularly.
No referral updates – John is not up-to-date with the progress of the referrals which makes referral loop closure impossible.

The lack of a systematic referral workflow increased the manual effort and makes it tedious to follow-up with patients and receive referral updates.

HealthViewX Patient Referral Management System

Considering the challenges faced by the patients, an automated Healthcare Patient Referral Management System is the need of the hour. Electronic healthcare referral management system helps healthcare organizations in the seamless processing of the referral process.

Let us review the same instance with HealthViewX Referral Management solution in place,

Patient visits the PCP – Andrews met with an accident recently. He met his PCP, Dr. John the next day as he was having pain in his leg. After examining him, Dr.John wanted him to consult an orthopedic. The doctor then initiated the referral.
PCP initiates the referral – John created a referral in HealthViewX system. HealthViewX does the insurance pre-authorization automatically in the background. With the help of the “Intelligent Smart Search” feature, he found an orthopedic. After giving the necessary information, John created the referral. The specialist got notified of the referral and all referral information were easily accessible by him.
Patient Disorientation – Andrews left the clinic with clear information about the specialist and appointment details. There was no need for him to call up the specialist for appointment as everything is automated. The patient will be notified about the appointment and tests to be taken.
Patient visits the specialist – Andrews met the orthopedic soon after the appointment was fixed. He got the best treatment and was satisfied with the referral process.

If you were Dr.John, would you not want Andrews to have a better experience? By using referral management software, you can ensure that Andrews’ knee pain heals while he also develops a positive opinion about your practice. Using a referral management software, you as a PCP can retain patients like Andrews in your network.

HealthViewX Patient Referral Management Solution features

Insurance Pre-authorization – HealthViewX solution supports automated insurance pre-authorization that reduces the manual work of the referral coordinators.
Intelligent Provider Match – The solution supports an “Intelligent Provider Match” Feature that helps in finding the right specialist/imaging center easily.
Seamless communication – HealthViewX solution has an inbuilt audio calling and messaging application which is secure and enables faster communication
HIPAA compliant data security – The solution is HIPAA-compliant and offers secure data exchange. It supports almost all formats of files and keeps the patient documents safe.
Referral history – The timeline view provides the history and current status of the referral. A status helps in knowing the referral progress.
Referral loop closure – Referral updates are hard to miss that makes it easier to close the referral loops on time.

HealthViewX Patient Referral Management application solves most of the challenges faced by the patients and PCPs. This increases patient satisfaction and revenue. To know more about HealthViewX solution, schedule a demo with us. Our patient referral management experts will guide you through our HIPAA-compliant solution.

Outsourcing Chronic Care Management In 2019 – Associated Benefits And Risks

Medicare has offered reimbursements to physicians for Chronic Care Management services since 2015. But still, providers are struggling with patient engagement, education, efficient processes and regulatory compliance.

CCM provider provides 20 minutes of monthly non-face-to-face care management services for beneficiaries with two or more chronic conditions. It helps in managing their conditions, risk factors, medication adherence, and coordination of care with other providers. To bill for CCM services, practices must offer

24/7 access to care management services
a platform for direct patient-practitioner communication
ability to manage transitions between providers and settings

Why are hospitals outsourcing CCM services?

CCM program is a labor-intensive process. It requires

Recruitment and training certified staff
EHR systems to track care plans
Monitor and document monthly calls
Making staff available to patients 24/7
More office space

In order to avoid these challenges, hospitals are outsourcing CCM services.

Advantages of outsourcing CCM services

New significant revenue stream – A small hospital cannot afford costly EHRs, handle staff-patient management, etc. These aspects are important for chronic care management implementation. Hence they are outsourcing CCM services. The outsourcing agencies specialize in CCM services and take a part of the profit from the practice. It generates a new significant revenue stream for practices who otherwise cannot get Medicare CCM reimbursements.
Saves physician’s time and effort – Outsourcing CCM services overcome the time-intensive CCM challenge for many physicians. Many of them do not have the professional staff bandwidth to provide the continuous chronic care management services. The new CMS initiative of paying doctors for CCM services works well with outsourcing.
Better patient satisfaction– The billing physician creates a specific healthcare plan for his patients. The physician then turns that plan over to the CCM vendor who is responsible for the daily or weekly contact with the patient. The CCM vendor monitors the patient’s progress and provides health coaching according to the physician’s care plan. The vendors must make sure that the patient is adhering to the plan and keep the physician posted. This allows the physician to extend his chronic care management to more patients with the required staff bandwidth.
Improved patient interaction – Outsourced services can combine technology, clinical services, and analytics with minimal efforts from the physician’s end. It results in improved patient interactions between actual office visits, with no impact on their current professional staff.
Increased patient enrollment – Outsourcing CCM will allow the physician to

increase and maximize patient enrollment in the program
improve patient compliance
provide CCM documentation requirements

while minimizing the physician’s workload.

Risks of outsourcing CCM services

1. Risk Management – Outsourcing CCM may sound easy on the front end, but it is very hard to mitigate the risks on the back end. Medicare fraud violations cost up to $10,000 per incident and may even subject the physician to a jail term. Outsourced CCM services make the practice actively and directly responsible for multiple risk factors:

Is the person performing the work appropriately credentialed to work in the state (especially nursing-staffed call centers)? Has the practice taken active steps to confirm this is?
Are all of the services billed for on the claims actually performed? Is the practice actively performing spot checks to ensure same?
Is the practice periodically checking that the documentation they receive for these claims and services is actually legitimate?
Is patient’ privacy taken care of? It is HIPAA-compliant?
Is the practice provided audit logs to protect them if they are audited? How often do they receive audit logs?

Never forget that an outsourced CCM vendor is paid on the volume while you hold 100% of the risk. At a minimum, this creates misaligned incentives and requires the practice’s perpetual and diligent oversight.

2. Profit factor – CCM vendors may take from half up to two-thirds of the CCM reimbursement for complete outsourced CCM service. When the added expenses are taken out of the payment, a practice may get only $7 to $12 per patient. In addition to paying the third party, it also has the labor cost of

Filing the claim
Paying the clearinghouse and the biller
Collecting $8 copay.
At one point, there is no profit from outsourced services

3. Patient’s experience – When a practice outsources the CCM services, the CCM vendor takes care of following up with the patients. Every time a patient gets a call, the person calling for rendering CCM service is unknown to them. The patients are not happy with different people calling them up every month. The vendors will not be fully aware of the patient’s medical history resulting in an average CCM call. The patient will also not feel good about talking to random people every month. Patients become dissatisfied with the outsources CCM services and leave the network.

4. Losing continuity with patients – In outsourced CCM, the practice does not get in touch with their patients regularly. When the patient visits the hospital, the physician will have to go through the previous CCM service history. It is better for the practice to do CCM services rather than give it to a CCM vendor. It affects the practice’s patient network and results in revenue loss.

Outsourced CCM services have a mix of advantages and risks. HealthViewX Chronic Care Management solution supports outsourced CCM as well as CCM services provided directly by the practice. The risk factor associated with outsourcing CCM is minimal in HealthViewX Chronic Care Management software.

HealthViewX Chronic Care Management solution features

HealthViewX Chronic Care Management solution has the following features that make the process simpler,

Inbuilt audio, video calling and messaging features – HealthViewX Chronic Care Management solution has inbuilt video and audio calling features. It helps in giving Chronic Care Management services to their patients. Secure messaging is also available through which the physicians and the patients can communicate.
Automated call log feature – After a call, care plan creation or any action related to CCM health services, the system automatically adds call logs. It reduces the physician’s manual effort is logging the call logs.
Preventive Care plans – HealthViewX solution supports care plans for the Chronic Care Management service for a patient. The physician can create a care plan depending on the patient’s health report. It helps in monitoring the patient’s vitals.
Chronic Care Management Analytics – Dashboards with intuitive charts and tables give complete analytics of the Chronic Care Management services. It provides a clear picture of the revenue perspective.
Consolidated Report – The physician can generate a consolidated report of the Chronic Care Management services given for a particular period. This makes it easy for the billing practitioner for getting the reimbursements.
HIPAA compliance – HealthViewX Chronic Care Management is HIPAA-compliant. It facilitates secure data exchange. The solution manages all patient-related documents securely.

HealthViewX Chronic Care Management solution has features that suit practices as well as CCM vendors. To know more about our Chronic Care Management solution, schedule a demo with us.

References

http://www.federalcharges.com/medicare-fraud-charges-penalties/

What is Complex Chronic Care Management – All you need to know

Chronic Care Management

The Centers for Medicare & Medicaid Services (CMS) considers Chronic Care Management (CCM) as a crucial part of primary care. Chronic Care Management is non-face-to-face care provided to Medicare patients with two or more chronic conditions. It contributes to better health services to people. In 2015, Medicare started to reimburse a certain amount for the Chronic Care Management services under the Medicare Physician Fee Schedule (PFS).

Service Codes

CPT 99487 – Complex chronic care management services with the following required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- Chronic conditions place the patient at significant risk of death, acute exacerbation, or functional decline
- Establishment or substantial revision of a comprehensive care plan
- Moderate or high complexity medical decision-making
- 60 minutes of clinical staff time directed by a physician or other qualified care provider, per calendar month
CPT 99489 – Each additional 30 minutes of clinical staff time directed by a physician or other qualified care provider, per calendar month (List separately in addition to code for primary procedure)

Difference Between CCM and Complex CCM

CCM (“non-complex” CCM) and complex CCM services have similar health service elements. They differ in the following aspects,

Amount of clinical staff service time provided
Involvement and work of the billing practitioner
The extent of care planning performed

According to Medicare, “Complex Chronic Care Management services of less than 60 minutes in duration, in a calendar month, are not reported separately. Practitioners must report CPT 99489 in conjunction with CPT 99487. They must not report CPT 99489 for care management services of less than 30 minutes along with the first 60 minutes of Complex Chronic Care Management services during a calendar month.”

Eligibility Criteria for Care Providers

Physicians and the following non-physician practitioners may bill CCM services:

Certified Nurse Midwives
Clinical Nurse Specialists
Nurse Practitioners
Physician Assistants

Patient Eligibility

Medicare provides Chronic Care Management services for patients with multiple (two or more) chronic conditions

Expected to last at least 12 months or until the death of the patient
Places the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline

As Chronic Care Management services have reimbursements, physicians must consider administering CCM to the eligible Medicare patients. The billing practitioner cannot report both complex and regular (non-complex) CCM for a given patient for a given calendar month. In other words, a given patient receives either complex or non-complex Chronic Care Management services during a given service period, not both.

Supervision

The Complex CCM codes (CPT 99487, 99489) come under the general supervision according to Medicare PFS. A billing practitioner need not give the health service personally. Any qualified care provider can give the service under the billing practitioner’s overall direction and control. The billing practitioner’s physical presence is not required.

CCM Service Summary

Care providers give a non-complex or complex Chronic Care Management service through the following steps,

Initiating Visit – Medicare requires initiation of CCM services for new patients or patients not seen within one year of commencement of CCM. It is a face-to-face visit with the billing practitioner. It includes an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or other face-to-face visits. This initiating visit is not part of the CCM service and is separately billed.
Structured Recording of Patient Information Using Certified EHR Technology – Structured recording of patient’s demographics, problems, medications, and medication allergies using certified Electronic Health Record (EHR) technology.
Comprehensive Care Plan – A person-centered, electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment. The care provider must,

Provide the patient and/or caregiver with a copy of the care plan
Ensure the electronic care plan is available and shared timely within and outside the billing practice to people involved in the patient’s care

24/7 Access & Continuity of Care – Provide 24/7 access to physicians or other qualified care providers or clinical staff and continuity of care with a designated member of the care team.
Enhanced Communication Opportunities – Enhanced opportunities for the patient to communicate with the physician through not only telephone access, but also the use of secure messaging, Internet, or other non-face-to-face consultation methods.

HealthViewX Chronic Care Management solution features

HealthViewX Chronic Care Management solution has the following features that make the process simpler,

Inbuilt audio, video calling and messaging features – HealthViewX Chronic Care Management solution has inbuilt video and audio calling features. It helps in giving Chronic Care Management services to their patients. Secure messaging is also available through which the physicians and the patients can communicate.
Automated call log feature – After a call, care plan creation or any action related to CCM health services, the system automatically adds call logs. It reduces the physician’s manual effort is logging the call logs.
Preventive Care plans – HealthViewX solution supports care plans for the Chronic Care Management service for a patient. The physician can create a care plan depending on the patient’s health report. It helps in monitoring the patient’s vitals.
Chronic Care Management Analytics – Dashboards with intuitive charts and tables give complete analytics of the Chronic Care Management services. It provides a clear picture of the revenue perspective.
Consolidated Report – The physician can generate a consolidated report of the Chronic Care Management services given for a particular period. This makes it easy for the billing practitioner for getting the reimbursements.
HIPAA compliance – HealthViewX Chronic Care Management is HIPAA-compliant. It facilitates secure data exchange. The solution manages all patient-related documents securely.

HealthViewX Chronic Care Management solution has features that satisfy non-complex and complex CCM services. Medicare reimbursements for Chronic Care Management services increase the profits for community health centers. It also benefits patients with multiple chronic health conditions. To know more about our Chronic Care Management solution, schedule a demo with us.

How To Control Patient Referral Leakage In Your Referral Network?

Health providers in a health system need patients to run their practice profitably. Be it a hospital, health network or private practice, healthcare providers rely on incoming referrals from other health providers and entities. Referrals generate revenue and improve patient retention rate. Providers tend to refer patients to specialists within the same hospital or health network. This is to retain them in the same hospital. A provider should consider factors such as personal relationships, quality outcomes, proximity, insurance coverage and patient preference before referring a patient. When a provider fails to consider these, patient referral leakage is bound to happen.

Patient Referral Leakage

Patient Referral Leakage happens when healthcare providers refer patients out-of-network. Accordingly, patient leakage is sometimes known as network leakage or referral leakage. The following definitions will help in better understanding of patient leakage,

In-Network – In-network refers to medical care within a network of doctors, hospitals, and other health providers who have a contract with a health insurance company. Inside the network, patients seek medical care only from those providers who are under the terms of the health insurance. In-network care is cheaper due to discounted rates that a health insurance company has negotiated ahead of time with the various health networks.
Out-of-Network – Out-of-network refers to patients looking to get medical care outside their current health network. This means that the patients seek care from out-of-network providers who cover their health insurance. Health providers refer patients seeking advanced treatment out-of-network. This is the main reason for patient leakage.

Why does patient referral leakage happen?

Sometimes patient referral leakage is unavoidable. When patients need medical care that is unavailable in their network, the health provider must understand the patient’s needs. The health provider must refer the patient to a specialist or an imaging center depending on the need.

However, there are occasions where in-network providers may refer patients to out-of-network providers on purpose.

Provider’s Repute – Sometimes, a health provider may refer their patients out-of-network to another provider who is more reputable in that specialty. This could be because the current health network has not employed a reputable specialist. The provider must make sure that a patient gets the best treatment possible.
Unaware of Providers in their network – Health providers who have just joined a health network or are a part joint ventures, acquisitions do not know all their specialists. This causes confusion and the health providers refer the patient out-of-network. When a health system fails to make it easy for health providers to refer within the network, patient leakage is inevitable.
Patient’s Choice – When certain treatment or care is not available within a network then it is up to the provider to refer the patient out-of-network. The health provider may recommend a next best course of treatment and the provider to consult for advanced treatment. Patients do tend to take the provider’s advice but it is up to the patient. This is why certain amounts of patient leakage will always exist. If the patient decides to move out of the practice due to unavoidable reasons then referral leakage becomes inevitable.

Why should it be curbed?

Patient’s Benefit – The patient may need immediate care and attention. So processing and closing it at the earliest will be the best for the patient. Patient leakage leads to open patient referral loop which will affect the patient’s health.
Patient’s Experience – A patient moves out-of-network due to many reasons. Primarily it is because the patient is not satisfied with the medical care provided in the current health system. Patient’s bad experience has a direct effect on hospital’s revenue, the number of incoming referrals, patient crowd, etc. In order to give efficient care to the patients, a health system must prevent patient leakage.
Missed Revenue and Reimbursement opportunities – The main problem with patient leakage is the missed revenue opportunities for health systems. These organizations miss out on reimbursement for medical services that they had provided earlier when patient leakage occurs. This applies to healthcare systems that adopt value-based care or payment models such as accountable care organizations (ACOs).
Failed relationships with healthcare providers and patients – Patient leakage results in failed relationships with healthcare providers and patients. Many health systems have spent resources on building clinical alignment with their referral network. Unfortunately, when patients go out of the system providers lose their trusted receiving providers.

How to tackle Patient Referral Leakage?

Employing right providers – Organizations can cut down patient leakage by employing respected, experienced, and well-regarded providers that they. This will cut down the number of patients who voluntarily go out-of-network. This is because they will find the right provider in their network.
Clear communication between physicians and patients – Clear communication between providers and patients is key to creating a positive patient experience and engagement. A health system can decide to give patients control of their own health by implementing an e-consult software. It should allow patients to schedule their own appointments, talk to providers online, order prescriptions, etc.
Being transparent in all aspects – The health system must be transparent about prices and pricing structure with the patients. Healthcare providers should give upfront estimates of costs and detailed end-of-care financial statements. Quality metrics is the other part that health networks must make readily available to the patients. It includes patient outcomes, patient satisfaction scores, physician reviews, etc. Ease of use and timely access to best care are crucial aspects of the patient experience. In a health system, it is important for a patient to receive medical care easily and in a timely manner.

How can HealthViewX Referral Management solution help?

Information Technology is transforming healthcare to a great extent. Patient referral leakage never happens with the help of a software application like HealthViewX. HealthViewX Patient Referral Management solution simplifies the referral process by the following steps,

Referral Initiation – The patient demographics and diagnosis required are already in the application. The referral coordinator can create the referral through a simple three-step form which includes health insurance pre-authorization, finding the right receiving provider with the help of “smart search”, etc. After finding the receiving provider, the referral coordinator refers the patient. When the receiving provider receives the referral, the provider will get notified of the referral.
Referral status and timeline view – With the help of a referral status, the referring provider can get to know what stage the referral is. A timeline view shows a history of stages through which the referral has progressed.
Referral and timeline view reports – The health provider can generate the timeline view and referral analytics data as a report in any form.
Referral closure and feedback – The referring provider can close the referral when it gets completed. The receiving provider and the patient can give a feedback on the referral process to the referring provider. Thus the referring provider can make it easy for the other the next time.

HealthViewX Patient Referral Management solution smooths the referral process and reduces the burden of the referring and the receiving ends. Referral Management software cuts down patient referral leakage to a considerable number. Do you want to know more about HealthViewX Patient Referral Management solution? Schedule a demo with us.