Tag Archives: patient

Referral Management Solution Is The Need Of The Hour For Large Hospitals

With the ever-evolving healthcare setting and exponential developments in health IT,  many choices need to be made by hospitals/health systems to provide their patients’ with quality care. Health systems are struggling to manage their clinical, operational and monetary challenges. Most importantly, it is necessary to orchestrate care teams’ workflow movements to be able to demonstrate meaningful use. This is the key to improving patient care and the ability to make better-informed decisions. A lot of providers are already adapting to smarter and new healthcare technologies to shape the future of healthcare.

Factors like sustainability, patient-centricity, care delivery, HIPAA compliance, digital health technology, etc. should be kept in mind before choosing any IT solution. Referral Management Solution is one such solution that is the need of the hour and it has to be chosen with utmost importance. Moving from volume-based to value-based care model will require building a solution to manage higher patient referral volumes, to ensure patients’ receive care within their referral network, track referrals, close referral loops, study dashboards and analytics for meaningful use, etc.  

There are a lot of benefits a referral management solution can bring to referring physicians, patients and receiving physicians: that includes, improved operational efficiency, reduced referral leakage, increased referral loop closures, increased revenue and patient satisfaction.

There are several other reasons why a referral management solution is required to manage patient referrals. Hospitals face numerous challenges in their referral process such as operational inefficiency, improper communication among providers, lack of coordination, missed referral loop closures, increased no-show rates, time consumption, etc.

Below are some alarming stats that show the need for a referral solution for hospitals

  • 46% of faxed referrals never result in a scheduled appointment.
  • 55% of specialist visits are unnecessary.
  • There is an annual leaked income of $900k per physician employed.
  • 50% of referring physicians do not know whether their patients actually see the specialist.

In addition, hospitals participate in passive referral management:

  1. Physician informs the patient about the need to see a specialist.
  2. Referral coordinators may not reach out to the patient to get an update to see if the patient had visited the specialist.
  3. Follow-up or update from the customer is completed only during the next visit.

Active referral management enables both provider and patient-driven processes to be managed by referral coordinators. It ensures maximum efficiency, finds the right provider for the patient, identifies referral patterns, improves stakeholder communication, reduces referral leakage, decreases lead time, improves completion rates, ensures closure of the referral loop and satisfaction of the patient.

Pitfalls in choosing the right Referral Management Solution:

Even though there are different referral management software with an array of features in the market, it often becomes frustrating to choose the right solution for your hospital. So before zeroing in on the solution, a detailed analysis of your current challenges in the patient referral process has to be carried out. Later mapping to the required features of the solution will be the best choice.

Health Systems need an end-to-end interoperable referral solution to track their patient referrals throughout the process until the referral loop closure. The solution should streamline and enable seamless communication among all stakeholders’ involved in-patient care.

Some of the benefits you can see when using patient referral software are

For the providers:

  • Reduce referral leakage and improved operational efficiency
  • Seamless communication
  • Multi-channel integration
  • Manage and track referrals
  • Meaningful engagement
  • Effective diagnosis and treatment

For the patients:

  • Prompt diagnosis
  • Save time and money
  • Better outcome

HealthViewX Referral Management Solution was created with the potential to solve all the challenges faced by enterprise hospitals in their referral process.

HealthViewX Referral Management Solution helps to send and receive referrals securely and seamlessly, provide quick access to patient data, fix appointments, send notifications and alerts, and share information throughout to ensure closure of referral loop. A 30-minute demo with our team will help you know how effective our solution can track and manage the referral life cycle. To know more schedule a demo with us.

FAQs – Chronic Care Management

Care providers across the United States of America are monetizing Medicare chronic care management billing reimbursement codes to increase revenue from their practice. Read on to find answers to all the most commonly asked questions about patient eligibility, the scope of services, CPT codes and payment reimbursement for Medicare CCM.

Patient Eligibility

FAQ: Are all Medicare patients eligible for CCM reimbursement?

Answer: According to the Centers for Medicare & Medicaid Services (CMS), CCM is for “patients with two or more chronic conditions. A chronic condition is expected to last at least 12 months or the patient’s entire lifetime. The condition should be diagnosed to place the patient at significant risk of death, or functional decline.

FAQ: How can a care provider decide which condition meets CMS’ definition for CCM eligibility?

Answer: CMS has not specified or listed the eligible chronic conditions that meet this definition. CMS does have a databank regarding chronic conditions (http://www.ccwdata.org) that care providers can use. However, this list is very narrow. In general practice, CMS requires a clear communication within the care plan that the chronic conditions being treated post a significant risk of death or functional decline.

FAQ:  Are there only certain diagnoses for which the CCM code can be reported?

Answer: There is not a defined list of diagnosis codes that meet the requirements of. What is required is that the chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline and that management requires a care plan. The AAN recognizes patients with two or more of the following conditions may be appropriate for the use of chronic care management services*:

  • Neurocognitive disorders including Alzheimer’s disease, Dementia, and Parkinson’s disease
  • Stroke with late effects that place the patient at risk for falls, fractures, and aspiration pneumonia
  • Poorly controlled diabetes mellitus

FAQ: What about patients who are Medicare beneficiaries but also eligible for Medicaid?

Answer: CMS CPT codes can be used while billing for CCM treatment given to Medicare beneficiaries who are also eligible for Medicaid.

FAQ: How to kick-start the process of bringing a patient under CCM care?

Answer: An initial appointment must be fixed for a comprehensive evaluation of the patient. This is known as a “Welcome to Medicare” visit and includes an initial preventive physical examination. A patient must have received an introduction to Medicare CCM billing in person to be able to bill separately for CCM services. Until the changes made in 2017, a consent form signed by the patient was mandatory during the patient’s initiation into the CCM program. As per the CMS requirement, the consent form is no longer mandatory.

FAQ – Can CCM services be reported if the patient/caregiver has not given consent?

Answer: No. One of the requirements for billing CCM services is “knowledge and recognition by the patient that the physician will perform care management services on the patient’s behalf.” In the event of an audit, documentation of patient consent in the patient record is crucial.

Scope of Services

FAQ: What are the scope of services for CCM reimbursement as defined by CMS?

Answer: CMS defines the scope of CCM services in the following way:

  1. Provide patients with access to care management services at any time of the day. This means patients should be able to contact the care provider during any emergency or urgent chronic care need 24-hours-a-day, 7-days-a-week. This may be through calls, SMS, email, internet applications or other means agreed upon by the patient and care provider.
  2. Established care continuity with a designated provider with whom the patient is able to schedule appointments, discuss care plan compliance, report vital stats and discuss any discomfort that arises.
  3. Creation of a patient-centered care plan document taking into consideration the physical, mental, functional and environmental factors of the patient. This includes an assessment of the support system and resources accessible to the patient.
  4. Care management for chronic conditions including assessment of patient’s medical, functional, and psychosocial needs. Regular follow-ups to ensure timely receipt of all recommended preventive care services, adherence to the suggested care plan and timely medication.
  5. Regular follow-up after a patient visits the emergency department, after discharges from the hospital or other healthcare facilities. Coordination with home/community based clinical service providers to support a patient’s care plan adherence.
  6. Use of certified electronic health record (EHR) and a patient consent form were mandatory until the changes in 2017 which made them optional.

Chronic Care Management CPT Billing Codes and Payment

FAQ: Which CMS Medicare billing codes can be used to bill CCM?

Answer: For the chronic codes that can be billed are below.

CPT Code Billing Amount(approx) per consultation Description
CPT99490 $42 Min 20min non-face to face time monitoring the care plan
CPT99480 $60 Min 60min non-face to face consultation time establishing or monitoring a care plan
CPT99489 $47 To be billed with CPT 99487 for every additional 30 min of non-face to face consultation


FAQ:  Are CCM services subject to Medicare’s co-paying system?

Answer: Yes. After the deductible is met, the 20 percent coinsurance charged to the patient will be about $8 to $9 for a month’s work of CCM with CPT 99490.

FAQ: Can you bill CCM for patients in an assisted living facility?

Answer: According to CMS, CPT code 99490 can be billed only for CCM services provided to a patient who is currently not the inpatient of a hospital. The patient must not be residing in a facility that receives payment from Medicare for that beneficiary.

FAQ: Is billing for CCM services limited to primary care physicians?

Answer: Physicians and Non-Physicians can claim reimbursement by billing for CCM CPT Codes. CCM code is most likely to be billed by primary care physicians. However, specialists, nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives who meet the requirements may also bill for these services.

FAQ: Can the non-face-to-face time spent creating the care plan count toward the 20 minutes necessary to bill 99490?

Answer: Yes, it can.

FAQ: What is the difference between chronic care management (99490) and complex chronic care management services (99487, 99489)?

Answer: Complex chronic care management services include the same criteria as the chronic care management service, plus an additional requirement of the establishment or substantial revision of a comprehensive care plan, medical decision-making of moderate to high complexity, and at least 60 minutes of clinical staff time.

Care Plan

FAQ: What does the care plan have to include as required by CMS?

Answer: The plan of care should include details of the following elements:

  • Problem list detailing the chronic conditions the patient suffers from
  • Expected outcome and the likely course of the disease
  • Measurable treatment goals
  • Symptom management
  • Planned interventions through regular follow-ups and vital data collection from patient
  • Medication management depending on any concerns/reactions/improvement reported by the patient
  • Care coordination plan between care provider and patient’s caregiver such as family/nurse/community housing etc
  • Requirements for periodic review and revision of the care plan as required.

FAQ: Do I have to provide the patient with a copy of the care plan?

Answer: Yes. CMS requires the care provider to share the care plan with the patient in a written or electronic format.

FQHC Statistics – Growth, Region, Performance and Revenue – Federally Qualified Health Centers across the USA

What are Federally Qualified Health Centers (FQHCs)?

Federally Qualified Health Centers (FQHCs) in the United States are non-profit entities that are composed of clinical care providers, who operate at comprehensive federal standards. FQHCs were originally intended to provide the medically underserved population with quality care to minimize patient load in hospital emergency rooms.

According to Medicare and Medicaid statutes, FQHCs receive federal funding under Section 330 of the Public Health Service (PHS) Act to provide comprehensive primary care services to uninsured and underinsured populations thus ensuring that comprehensive care is available to all, regardless of income or insurance status. Medicare pays FQHCs based on the FQHC Prospective Payment System (PPS) for medically necessary primary health services and qualified preventive health services given by an FQHC practitioner.

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

The Growth of FQHCs

In the early 1960s, there were only 8 health centers in the U.S. Ever since then, the numbers have increased exponentially. By 2001, there were 748 health centers at 4,128 service sites around the nation, serving approximately 10 million individuals.

Federal funding for health centers has increased from $750 million in 1996 to $2.2 billion in 2010. Federal support has increased tremendously over the last 10 years. In 2011, there were 1,128 health centers providing care to more than 8,000 rural and urban delivery sites in the U.S. and territories. Today, there are 1,400 organizations with 11,200 facilities serving about 25 million individuals every year.

The above chart shows the growth of health centers from its inception in 1980 till 2020. The chart also shows the exponential increase in the number of patients served over the years.

FQHCs in various regions across the U.S

State State Code Number of FQHCs
California CA 178
Texas TX 73
New York NY 70
Florida FL 48
Ohio OH 47
Illinois IL 45
Pennsylvania PA 44
North Carolina NC 40
Michigan MI 39
Massachusetts MA 39
Georgia GA 35
Louisiana LA 36
Oregon OR 33
West Virginia WV 31
Tennessee TN 30
Alaska AK 28
Missouri MO 28
Washington WA 27
Virginia VA 26
Indiana IN 25
Kentucky KY 23
New Jersey NJ 23
South Carolina SC 23
Arizona AZ 21
Mississippi MS 21
Colorado CO 21
Oklahoma OK 20
Maine ME 20
Kansas KA 18
Maryland MD 17
Montana MT 17
New Mexico NM 17
Wisconsin WI 18
Connecticut CT 17
Minnesota MN 16
Alabama AL 15
Hawaii HI 14
Iowa IA 14
Idaho ID 14
Puerto Rico PR 14
Utah UT 13
Arkansas AR 12
New Hampshire NH 11
Vermont VT 11
District of Columbia WDC 8
Rhode Island RI 8
Nebraska NE 7
Nevada NV 7
Wyoming WY 6
South Dakota SD 5
North Dakota ND 4
Delaware DE 3
Virgin Islands VI 3
Guam GU 2
Northern Mariana Islands MP 2

Performance of FQHCs

Figure 2 - Health Centers Perform Better on Ambulatory Care Quality Measures than Private Practice Physicians

Figure 2 – Health Centers Perform Better on Ambulatory Care Quality Measures than Private Practice Physicians

The above chart shows how health centers have outperformed private practice physicians in every aspect of service.

Figure 3 - Health Centers Provide More Preventive Services than Other Primary Care Providers

Figure 3 – Health Centers Provide More Preventive Services than Other Primary Care Providers

The above chart shows a comparison between health centers and other providers based on the number of patient visits for various ailments.

Figure 4 - Health Center Patients Are More Satisfied with the Overall Care Received Compared with Low Income Patients Nationally

Figure 4 – Health Center Patients Are More Satisfied with the Overall Care Received Compared with Low Income Patients Nationally

The above chart shows the level of satisfaction of low-income patients. Health center patients have a huge level of satisfaction as compared to other low-income patients nationally.

Financing and Reimbursements for FQHCs

FQHCs are required by law to provide services to all people, regardless of ability to pay. The uninsured are charged for services on a board-approved sliding-fee scale, which is based on a patient’s family income and size.

FQHCs are financed through various methods. These include a mix of Medicaid and Medicare reimbursements (with different payment methodologies), direct patient revenue, other third-party payers (private insurers), state funding, local funding, philanthropic organizations, and grant funding from the Bureau of Primary Health Care (BPHC) of HRSA of the U.S. Department of Health and Human Services (HHS).

The above chart shows the revenue distribution of FQHCs based on payer source (2018).

FQHC Revenue across all regions in the U.S (approx. 2018)

Source:
George Washington University analysis of the Health Resources and Services Administration’s Uniform Data System. Special Data Request, September 2019.

Location Medicaid Medicare Private Insurance Self-Pay Federal Section 330 Grants Other Grants and Contracts Other Total
United States $12,958,743,457 $2,260,247,981 $3,048,512,406 $1,248,741,884 $4,829,287,467 $3,336,624,219 $1,007,447,180 $28,689,604,594
Alabama $52,785,795 $17,803,287 $17,114,860 $12,744,350 $83,625,546 $13,471,556 $4,344,085 $201,889,479
Alaska $102,348,854 $18,671,815 $37,698,230 $6,477,465 $67,692,068 $119,544,705 $2,756,393 $355,189,530
Arizona $337,972,854 $47,634,000 $71,949,881 $23,395,361 $83,428,217 $41,485,739 $5,472,766 $611,338,818
Arkansas $62,148,511 $24,046,228 $30,622,521 $12,429,111 $54,555,352 $9,120,521 $1,735,385 $194,657,629
California $3,704,343,504 $411,514,109 $291,192,054 $148,976,225 $658,760,061 $615,047,232 $334,581,140 $6,164,414,325
Colorado $319,775,816 $39,134,784 $48,657,089 $30,779,398 $106,101,957 $95,942,011 $20,709,084 $661,100,139
Connecticut $228,434,332 $32,127,164 $26,544,878 $11,568,619 $59,696,129 $50,791,682 $10,598,421 $419,761,225
Delaware $11,773,644 $1,479,685 $2,463,464 $4,386,233 $13,557,989 $5,219,063 $470,309 $39,350,387
District of Columbia $160,105,430 $22,175,379 $32,105,709 $5,512,030 $27,476,019 $31,943,055 $7,236,844 $286,554,466
Florida $391,497,340 $60,674,510 $209,954,679 $81,714,253 $236,911,216 $193,834,424 $17,832,728 $1,192,419,150
Georgia $66,177,853 $48,142,417 $57,295,748 $30,758,262 $117,787,006 $28,848,026 $9,877,675 $358,886,987
Hawaii $107,408,992 $15,806,563 $17,253,126 $5,783,071 $31,398,131 $32,520,603 $3,907,118 $214,077,604
Idaho $45,572,373 $21,289,644 $50,122,229 $22,535,206 $45,993,298 $25,577,164 $3,267,335 $214,357,249
Illinois $455,197,448 $56,238,990 $131,100,822 $64,116,380 $201,027,383 $137,469,419 $29,398,121 $1,074,548,563
Indiana $200,004,374 $20,647,447 $30,284,051 $18,433,251 $75,547,860 $28,756,217 $30,759,622 $404,432,822
Iowa $83,853,103 $13,542,737 $23,553,367 $12,655,645 $38,528,294 $19,319,034 $1,624,245 $193,076,425
Kansas $37,808,462 $19,789,301 $26,840,099 $15,221,728 $44,761,541 $16,668,896 $4,665,564 $165,755,591
Kentucky $176,573,940 $46,631,367 $68,598,016 $24,819,874 $80,881,354 $6,773,516 $6,597,845 $410,875,912
Louisiana $146,815,697 $31,043,111 $59,995,751 $11,587,230 $100,474,957 $30,961,276 $4,441,509 $385,319,531
Maine $41,882,541 $35,423,228 $47,436,524 $12,099,407 $43,787,648 $11,360,335 $6,280,495 $198,270,178
Maryland $150,688,381 $29,260,626 $73,964,146 $13,146,680 $57,449,364 $35,657,860 $21,090,583 $381,257,640
Massachusetts $362,280,706 $103,012,238 $165,134,454 $27,248,100 $128,238,080 $258,007,270 $160,820,426 $1,204,741,274
Michigan $314,285,715 $68,214,766 $79,638,020 $28,291,497 $127,807,919 $44,375,118 $9,855,849 $672,468,884
Minnesota $75,452,268 $12,577,519 $16,837,190 $11,935,453 $42,977,632 $29,987,097 $4,128,981 $193,896,140
Mississippi $32,037,428 $18,436,338 $22,813,575 $21,440,111 $74,626,865 $14,886,816 $1,657,237 $185,898,370
Missouri $255,311,813 $26,546,831 $59,184,521 $28,003,100 $110,804,809 $33,834,797 $10,235,337 $523,921,208
Montana $34,073,242 $12,203,723 $17,685,163 $7,521,912 $42,126,575 $10,185,208 $6,307,871 $130,103,694
Nebraska $19,899,828 $1,982,820 $13,342,672 $7,991,555 $22,106,057 $22,906,355 $1,933,464 $90,162,751
Nevada $33,773,688 $11,166,606 $12,531,690 $3,172,460 $21,069,529 $15,948,721 $706,509 $98,369,203
New Hampshire $21,695,854 $17,132,960 $22,653,425 $5,099,829 $24,039,213 $11,899,812 $2,725,189 $105,246,282
New Jersey $158,938,887 $11,758,143 $14,145,131 $21,606,309 $81,666,571 $69,281,662 $5,982,249 $363,378,952
New Mexico $132,429,129 $26,364,684 $24,132,532 $15,923,683 $76,523,082 $57,190,428 $4,530,396 $337,093,934
New York $1,461,356,192 $201,623,297 $250,926,163 $50,171,017 $269,626,284 $385,124,022 $91,523,863 $2,710,350,838
North Carolina $90,190,949 $59,012,065 $65,516,943 $50,837,624 $133,899,942 $40,248,341 $26,574,283 $466,280,147
North Dakota $11,640,795 $3,863,326 $9,419,592 $4,474,860 $10,746,019 $908,251 $1,001,661 $42,054,504
Ohio $261,827,729 $51,042,970 $58,596,828 $25,007,037 $146,210,064 $41,839,517 $21,051,011 $605,575,156
Oklahoma $58,934,312 $20,089,581 $28,480,968 $19,992,107 $58,679,531 $10,582,038 $2,883,612 $199,642,149
Oregon $394,118,738 $51,503,384 $31,974,615 $15,310,703 $91,700,505 $91,028,195 $7,602,558 $683,238,698
Pennsylvania $315,531,242 $68,519,997 $104,374,387 $17,072,987 $128,243,325 $37,490,171 $10,326,309 $681,558,418
Rhode Island $109,670,334 $15,761,096 $19,797,174 $5,830,348 $28,040,434 $14,890,907 $4,960,361 $198,950,654
South Carolina $95,328,346 $89,583,350 $103,316,045 $25,145,381 $89,314,251 $31,444,029 $18,322,528 $452,453,930
South Dakota $11,514,028 $4,903,220 $10,207,221 $6,525,886 $17,900,812 $3,435,235 $1,231,547 $55,717,949
Tennessee $80,779,671 $26,920,974 $41,375,639 $15,091,806 $87,348,642 $31,856,403 $3,747,729 $287,120,864
Texas $405,350,935 $68,050,313 $170,985,325 $92,159,958 $258,162,160 $309,998,557 $26,687,781 $1,331,395,029
Utah $29,700,875 $11,520,256 $16,681,038 $13,794,751 $39,878,950 $24,880,704 $3,574,692 $140,031,266
Vermont $47,210,527 $31,973,872 $34,695,192 $23,137,643 $23,463,366 $7,348,657 $8,511,984 $176,341,241
Virginia $54,549,880 $39,744,588 $42,438,653 $26,005,991 $85,805,735 $20,677,091 $4,357,021 $273,578,959
Washington $769,937,162 $89,428,910 $129,151,433 $58,320,292 $139,027,744 $94,896,347 $14,596,022 $1,295,357,910
West Virginia $116,781,516 $57,847,408 $83,808,357 $28,402,025 $68,591,429 $16,910,711 $12,143,151 $384,484,597
Wisconsin $149,327,704 $8,202,250 $27,257,452 $10,451,845 $45,790,614 $27,262,928 $7,630,433 $275,923,226
Wyoming $6,918,264 $4,226,082 $5,490,411 $3,411,365 $7,478,734 $1,763,502 $477,559 $29,765,917
American Samoa $786,753 $0 $0 $0 $3,082,370 $0 $0 $3,869,123
Federated States of Micronesia $0 $0 $24,112 $84,319 $3,186,592 $0 $0 $3,295,023
Guam $2,451,828 $53,941 $17,002 $132,489 $2,173,874 $2,330,520 $137,227 $7,296,881
Marshall Islands $0 $0 $0 $31,865 $1,061,772 $1,086,917 $0 $2,180,554
Northern Mariana Islands $98,987 $641 $7,161 $11,185 $677,559 $0 $122,655 $918,188
Palau $0 $0 $259,006 $1,461,345 $940,810 $50,000 $0 $2,711,161
Puerto Rico $153,566,707 $33,237,486 $10,276,689 $7,922,019 $103,150,074 $16,880,374 $3,452,418 $328,485,767
U.S. Virgin Islands $7,822,181 $665,954 $589,383 $581,248 $3,678,153 $4,875,184 $0 $18,212,103

Definitions:
*Medicaid*: also includes the Children’s Health Insurance Program (CHIP), family planning programs, and state-funded coverage programs.

*Private Insurance*: includes employer-sponsored insurance and insurance purchased in the individual market (including the Marketplaces).

*Federal Section 330 Grants*: grants provided by the Health Services Resources Administration, Bureau of Primary Health Care under Section 330 of the Public Health Service Act.

*Other Grants and Contracts*: includes federal grants other than Section 330 grants, grants from state and local governments and private foundations, payments from state and local indigent care programs, and contracts.

*Other*: includes non-patient related revenue, such as fundraising, interest income, rent from tentants, etc.

Future of FQHCs

FQHCs have had significant growth in the past decades. The statistical data indicates that FQHCs have the potential to serve more patients by improving the quality of care. To provide quality care and improve patient experience, FQHCs must invest in the right technology like HealthViewX Care Orchestration Platform which provides the best solutions for the major challenges faced by the health centers.

Reference:

  1. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/fqhcfactsheet.pdf
  2. Kaiser Commission on Medicaid and the Uninsured (data from the National Association of Community Health Centers and the Uniform Data System (UDS) of the Health Resources and Services Administration (HRSA).
  3. Goldman, LE et al. Federally Qualified Health Centers and Private Practice Performance on Ambulatory Care Measures. American Journal of Preventive Medicine. 2012. 43(2):142-149. *Fontil et al. Management of Hypertension in Primary Care Safety-Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians’ Offices. Health Services Research. April 2017. 52:2.
  4. 2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. National Center for Health Statistics. NCHS Data Brief. No. 220. November 2015. Hypertension Prevalence and Control Among Adults: United States, 2011 – 2014. National Committee for Quality Assurance. Comprehensive Diabetes Care, The State of Healthcare Quality (2016).
  5. Shi L, Tsai J, Higgins PC, Lebrun La. (2009). Racial/ethnic and socioeconomic disparities in access to care and quality of care for US health center patients compared with non-health center patients. J Ambul Care Manage 32(4): 342 – 50. Shi L, Leburn L, Tsai J and Zhu J. (2010). Characteristics of Ambulatory Care Patients and Services: A Comparison of Community Health Centers and Physicians’ Offices J Health Care for Poor and Underserved 21 (4): 1169-83. Hing E, Hooker RS, Ashman JJ. (2010). Primary Health Care in Community Health Centers and Comparison with Office-Based Practice. J Community Health. 2011 Jun; 36(3): 406 – 13.
  6. Shi L, Lebrun-Harris LA, Daly CA, et al. Reducing Disparities in Access to Primary Care and Patient Satisfaction with Care: The Role of Health Centers. Journal of Health Care for the Poor and Underserved. 2013; 24(1):56-66.
  7. George Washington University analysis of the Health Resources and Services Administration’s Uniform Data System. Special Data Request, March 2018.
  8. Community Health Center Revenues by Payer Source.

Five ways In Which HealthViewX Referral Management Can Fix The Referral Problems Of Enterprise Hospitals?

Existing Patient Referral Management Workflow in Large Enterprise Hospitals

In order to understand how a patient referral works in a large enterprise hospital, let us consider a scenario,

XYZ hospital is a large enterprise hospital with 10,000 plus PCPs and specialists. It is a busy hospital that sends and receives 1000 plus referrals in a day.

  1. Mark visits the hospital – Mark hurt his leg and was bleeding. Even after three days, the wound did not heal. He visited his PCP, Dr. James. After examining Mark, Dr.James wants him to consult a diabetologist.
  2. Dr.James does the insurance pre-authorization – The PCP does the insurance authorization manually. He places a request with the insurance company and waits for their response. The process takes time and forces Mark to wait. After about four hours, Dr.James gets the consent of the insurance company for the diagnosis.
  3. Dr.James has difficulty finding the right specialist – St.Luke’s hospital had recently acquired a specialty clinic. Dr.James is not aware of the specialists recently added to the network. So he misses the famous diabetologist within the network and looks for someone outside the network. After considering many factors like the patient’s comfort, specialist’s availability, distance from the patient’s residence, specialist’s experience etc, he finally chooses a receiving provider.
  4. Dr.James sends the referral – Dr.James finally sends the referral to Dr.Hales after trying to reach the specialist office via phone. The line seems to be engaged. He looks for many other ways which will be easy to send referrals but to his disappointment, Dr.Hales accepts only referrals through phone or website.
  5. Dr.Hales schedules appointments – After receiving the referral, Dr.Hales schedules an appointment with the patient. Mark was not notified clearly about the appointment. So he fails to show up. It results in revenue loss for the specialist and patient dissatisfaction with the PCP. Mark who is still suffering from pain and waiting for the specialist to examine him. After two missed appointments, Mark finally visits the specialist.
  6. Referral progress updates and loop closure – Throughout the referral process, Dr.James is in the dark. Dr.Hales is busy and fails to give referral updates to Dr.James. He is anxious to know if Mark was taken care of. Without referral updates, Dr.James cannot close the referral loop.

Challenges faced by Enterprise Hospitals

  1. Insurance pre-authorization – The process of waiting for the insurance company to respond and approve the procedures or medication is time-consuming. If this process is automated it would save time and efforts of providers, insurance companies, and patients.
  2. Finding the right receiving provider – As many of the enterprise hospitals are joint ventures or acquisitions, the PCPs are not completely aware of the specialists within their network. Many times, the PCPs refer their patients to specialists out of their network. Finding the right provider outside the network is the greatest challenge as the PCP has to consider many factors. It is time-consuming and prone to errors when done manually.
  3. Patient Referral Leakage – When a PCP refers the patient out-of-network, it leads to referral leakage. PCP can avoid Patient referral leakage if the patient is referred within the network. When that is difficult, patient referral leakage is inevitable. If the patient is referred out-of-network and is not happy with the care given, the chances of the patient coming back to the PCP is less. Referral leakage causes revenue loss and patient dissatisfaction.
  4. Referral Analytics –  As a large number of referrals flow in and out of the network, it is difficult to track the exact number. It is also tedious to track the number of referrals in various status and to close referral loops.
  5. Referral updates and referral loop closure – When PCP refers patients out-of-network, the chances of getting referral updates are minimal. The specialist is usually busy and does not update the referring provider about the referral. Referral updates are crucial in closing referral loops.

HealthViewX Patient Referral Management Workflow in Large Enterprise Hospitals

Let us consider the same scenario used earlier and see the benefit of HealthViewX referral software to the existing workflow in Large Enterprise Hospitals,

  1. Mark visits the hospital – Mark hurt his leg and was bleeding. Even after three days, the wound did not heal. He visited his PCP, Dr. James. After examining Mark, Dr.James wants him to consult a diabetologist.
  2. Dr.James does the insurance pre-authorization – The PCP does the insurance authorization in the HealthViewX application. HealthViewX places a request with the insurance company and coordinates with them thereafter. The process takes place quickly and gets over in about 15 minutes Dr.James gets the consent of the insurance company for the diagnosis.
  3. Dr.James finds the right specialist in no time – St.Luke’s hospital had recently acquired a specialty clinic. Dr.James is not aware of the specialists recently added to the network. He need not worry as the HealthViewX application is updated with the current list of providers. With the help of the Intelligent Smart Search feature, Sr.James found the right specialist in his network.
  4. Dr.James sends the referral – Dr.James sends the referral to Dr.Hales via HealthViewX application. It supports many channels of referrals like email, website forms, type-enabled pdf, fax, online forms, etc. With the HealthViewX solution, sending out referrals takes not more than five minutes.
  5. Dr.Hales schedules appointments – After receiving the referral, Dr.Hales schedules an appointment with the patient. Mark is notified clearly about the appointment. He meets the specialist on time and gets treated. This improves his satisfaction and Mark plans to visit the hospital in case of any illness.
  6. Referral progress updates and loop closure – HealthViewX application supports a Timeline View that is available to both the referring and receiving providers. It says all about the referral and its history. Dr.Hales is not required to update Dr.James as it is taken care of by the application. Without referral updates, Dr.James can close the referral loop without any delay. Dr.James can receive feedback about the referral from the patient and the specialist. Depending on their remarks, he can improve the process in future.

HealthViewX Patient Referral Management solution is the best choice for Large Enterprise Hospitals. Are you a Large Enterprise hospital looking for a referral management solution to solve your referral challenges? Schedule a demo with us. Our solution experts will be happy to guide you through our HealthViewX HIPAA compliant Patient Referral Management solution.

Improving Patient Referral Management Workflow Between Federally Qualified Health Centers & Specialists Clinics/Imaging Centers

Federally Qualified Health Centers and what do they do

A Federally Qualified Health Center (FQHC) is a community-based organization that provides comprehensive primary care and preventive care, including health, oral, and mental health/substance abuse services to persons of all ages, regardless of their ability to pay or health insurance status. Thus, they are a critical component of the health care safety net. FQHCs are called Community/Migrant Health Centers (C/MHC), Community Health Centers (CHC), and 330 Funded Clinics. FQHCs are automatically designated as health professional shortage facilities. a non-profitable, consumer-directed healthcare organization. FQHC serves the underserved, underinsured and uninsured people, and provides them with access to high quality and preventive medical health care. FQHCs were originally meant to provide comprehensive health services to the medically underserved to reduce the patient load on hospital emergency rooms.

FQHCs include community health centers, migrant health centers, health care for the homeless health centers, public housing primary care centers, and health center program “look-alikes.” They also include outpatient health programs or facilities operated by a tribe or tribal organization or by an urban Indian organization. FQHCs are paid based on the FQHC Prospective Payment System (PPS) for medically-necessary primary health services and qualified preventive health services furnished by an FQHC practitioner.

Their mission has changed since their founding. Their mission now is to enhance primary care services in underserved urban and rural communities

Patient Referral Management in Federally Qualified Health Centers

Federally Qualified Health Centers comprises of PCPs who offer primary health care services and related services to residents of a defined geographic area that is medically underserved. Many patients visit a PCP in a day. Federally Qualified Health Centers do not have the facilities for giving specialized treatments or for taking advanced tests. So, when a patient requires any specialist medical attention, the PCP refers him/her to the most suitable imaging center or specialty practice.

Federally Qualified Health Centers mostly refer their patients out of the network. The referral workflow from the perspective of a referring provider is as follows.

  • The PCP sends the referral through the EHR/EMR to the referral coordination team.
  • The referral coördinator will study the patient demographics and understand the required diagnosis.
  • The team coordinates for insurance preauthorization to cover the medical expenses for the required treatment/services.
  • Based on these, the referral coordinator will find the right specialist or imaging center for further diagnosis.
  • After finding the right specialist or imaging center, the patient details are sent out as a referral.
  • Community Health Systems sends referrals through various sources like phone, fax, email, etc.
  • The referral coordinator chooses the source depending on the receiving provider’s convenience.

The gap between the Federally Qualified Health Center and specialty care

A referral process may become inefficient and ineffective if the Federally Qualified Health Centers and the specialty clinics/imaging centers fail to communicate. When there is no proper communication from the specialty centers/imaging centers the community healthcare network finds it difficult to understand the progress of the referral. Let us see it from different perspectives to understand why there is a communication gap.      

  • From a referring provider’s perspective, the referral coordinator receives and processes many referrals every day. After sending out a referral, it is very difficult to follow-up with it manually. There are no effective and secure means of communication between the referring and the receiving providers. If the receiving provider or the patient fails to update the progress of a referral to the referring provider, he/she will never get to know what happened with the referral. Closing the referral loop becomes nearly impossible in this case.
  • From a receiving provider’s perspective, the referral he/she receives may contain incomplete information. Without vital details, processing the referral will be difficult. The source of referral are many but there is no single interface to manage it all. Missing out on referrals is common. There is no way of getting a consolidated data on the number of referrals missed and the number processed. Patient referral leakage becomes imminent if the referrals remain unprocessed for a long time.
  • From a patient’s perspective, the physician refers him/her to take tests in an imaging center and then meet a specialist to continue with the treatment. If the patient has to communicate back and forth between the referring and the receiving providers for incomplete information, history of illness, etc, it annoys the patient. It is frustrating for the patient to communicate between the two ends.

Referrals become incomplete, inefficient and ineffective when the participants fail to communicate and share timely information.

Guidelines to bridge the gap between Federally Qualified Health Centers and Specialist Clinics/ Imaging Centers

  1. The referring provider must understand the reason for the referral. The referring provider should also make the patient understand why a referral is necessary and what the patient can expect from the referral visit. Give time for questions and encourage the patient to clarify their doubts during the referral appointment.
  2. When the referral coordinator does the insurance pre-authorization, he/she must make sure that the receiving provider covers the insurance policy of the patient. This will keep the patient better informed of how much the service will cost.
  3. It is better for the referral coordinator to contact the specialist directly. He/She can give information about the patient’s current situation, as well as other medical records, test results, and documents to avoid duplication of effort.
  4. Both the sides have to agree on the urgency of the referral and discuss the duration of the process, frequency of referral updates and the mode of communication.
  5. Any tool that can give prompt reminders on the appointments, follow-ups to both the patient and the receiving providers can help.
  6. After the referral reports arrive, the provider must check the results and recommendations. If the referring provider cannot understand the specialist’s evaluation, he should contact the specialist to understand the diagnosis better.
  7. Referral is an important part of patient care but the patients are not obligated to follow-up with the specialist. If the referral isn’t completed, the referring provider must talk to the patient during the next visit to find out why. Documenting this can help in directing future referrals to the right specialist or imaging center.

HealthViewX Patient Referral Management solution communicates effectively between the referring and the receiving ends. The timeline view and referral status help in tracking the referral. Prompt reminders will never let you miss an appointment or follow-up. To know our solution better, schedule a demo with us.

Why Is Documenting A Medical Referral Not Easy For A Federally Qualified Health Center?

How does referral works in a Federally Qualified Health Center?

Federally Qualified Health Centers (FQHCs)  are private, non-profit organizations that directly or indirectly (through contracts and cooperative agreements) provide primary health services and related services to residents of a defined geographic area that is medically underserved. Federally Qualified Health Centers are high referral outbound centers, who send out a number of referrals in a day. A Federally Qualified Health Center has many PCPs who attend to numerous patients with different health problems. The PCP initiates referrals when the patient needs an additional diagnosis from an imaging center or a specialist practice. The following are the steps through which a referral flows,

  1. Referral Initiation – The referring provider gives the details of the patient and diagnosis to the central referral coordinating team. A referral coordinator will study the demographics of the patient and the diagnosis required.
  2. Insurance Pre-authorization – If the patient has an insurance coverage, the referral coordinator will validate the same. This step helps in finding out which imaging center or specialist practice will cover the medical expenses.
  3. Finding the right provider – Depending on the treatment required, insurance coverage, patient’s convenience, the referral coordinator will narrow down the search and find the right receiving provider for the referral.
  4. Sending out the referral – After finding the right provider, patient information and the diagnosis details are shared while referring. The physicians can share the information via phone, fax, email, etc depending on the source that suits the receiving provider.

Medical referral history documentation in Federally Qualified Health Centers

Referral history gives details of what has happened with the referral till date. The referral history is equally important to both the referring and receiving providers. Unfortunately, the receiving provider maintains this history through paper-based forms or EHR and it is not easily accessible to the referring provider. Documenting a medical referral is quite a challenge for the provider who initiates the referral. So what factors make it so tedious and challenging?

  • Physicians get busy – After the referral is initiated, the referring provider gets busy with other appointments and forgets about the referral until the receiving provider gives updates. Not to forget the receiving provider is also a specialist or from an imaging center who will also be busy. The receiving provider or the patient fails to communicate with the referring provider regarding the progress of the referral which makes it difficult to document the referral.
  • Lack of effective modes of communication – There is no effective platform to share patient’s sensitive data or communicate with the referring or receiving provider. The physicians are not available over calls or messages which makes the situation worse. There is a need for a standard HIPAA compliant application that the referring and receiving providers can use to share information which helps in referral documentation.
  • Manual effort making the referral process tedious – The referral process has manual intervention at every stage. This frustrates the providers and the referral coordinating team. Giving timely updates to the referring provider regarding a referral is too much of effort for the receiving provider. Documenting the referral manually becomes a challenge.

Why document a medical referral?

  • Patient’s need – The patient may come to the clinic at any time looking for the medical history of the referral. At that point, the clinic should be able to give the patient the medical referral history. So documenting a referral becomes a necessary process.
  • Clinic’s records for future reference – It is important for a Federally Qualified Health Center to maintain a history of its patient’s demographics and referral records. If the patient comes back to the clinic with an illness, these records will help in understanding the patient better and giving the best treatment the patient needs.
  • Direct future referrals – A history of medical referral records will help the physician in figuring out who responds quickly and who does not. The next time the physician sends out a referral, he/she will choose the most responsive and the most suitable receiving provider for the referral.

Information Technology to aid Federally Qualified Health Centers

Information Technology is transforming healthcare to a great extent. Documenting a medical referral is easy for a healthcare based software application like HealthViewX. HealthViewX Patient Referral Management solution simplifies the referral process by the following steps,

  1. 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 insurance pre-authorization, finding the appropriate receiving provider with the help of  “smart search”, etc. The receiving provider is notified of the referral.
  2. Referral status and timeline view – With the status, a referral is tagged to, the referring provider can get to know in what stage the referral is. A timeline view shows a history of stages through which the referral has progressed.
  3. Referral and timeline view reports – The timeline view and the referral analytics data can be generated as a report in any form chosen.
  4. Referral closure and feedback – If the referral is completed, the status can be changed to closed. A feedback form is generated for the patient and the receiving provider. This can help the referring provider in making the referral process better next time.

HealthViewX Patient Referral Management solution smoothes out the referral process and reduces the burden of the referring and the receiving ends of Federally Qualified Health Centers. Do you want to know more about HealthViewX Patient Referral Management solution? Schedule a demo with us.