Referrals, whether they are from a primary provider (first-party referral) or a secondary referral (specialist-to-specialist referral), require more than just a script to seek further treatment from another provider.
Posted in Risk Management on Friday, February 16, 2018
Referrals also require more effort than sending along a letter or fax to the subsequent treater with basic information about the patient and the reason for the referral. They are a process that requires communication and tracking. How and what information is communicated and tracked is vital when it comes to patient safety and patient compliance.
Claims involving referrals are on the rise. According to the Institute for Healthcare Improvement (IHI), more than 100 million referrals are requested annually in the U.S. With only half being completed, it is best to cover your bases when you refer a patient. Claims related to referrals are usually due to a missed or delay in diagnosis.
As the health care provider, you are responsible for ensuring referrals are completed in a timely manner and meet the needs of your patients. You can do this by establishing relationships with other providers, setting expectations for both the patient and the specialist, and assisting your patients through the referral process.
The IHI recently released “A Guide to Safer Ambulatory Referrals in the EHR Era.” The principals can be applied to all lines of health care. Although the report was for practices using EHRs, the information also applies to offices using paper charts.
The IHI expert panel identified nine steps to complete a “closed loop” referral process. In the nine steps, they recognized potential barriers and offered suggestions for overcoming those obstacles. This is good information and worth consideration as you can incorporate the following steps into your referral process.
- The primary provider orders a referral
- Defensive Strategy: Make sure you have a list of appropriate specialists; know what they need prior to their evaluation (including clinical and insurance information)
- The primary provider communicates the referral to the specialist
- Defensive Strategy: Include urgency status, differential diagnosis, concerns and desired input from the consultant (expectations)
- The referral is reviewed and authorized by insurance
- Defensive Strategy: Primary provider confirms insurance authorization/specialist in patient’s network
- The appointment is scheduled and tracked
- Defensive Strategy: Address who schedules the appointment (PCP, Specialists or Patient); patient engagement and accountability for follow up
- The consult occurs
- Defensive Strategy: Primary provider track maintains contact with specialists regarding no shows
- The specialist communicates the plan to the patient
- Defensive Strategy: Specialist makes sure patient understands the care plan
- The specialist communicates the plan to the primary provider
- Defensive Strategy: Make sure communication to the patient is same message communicated to referring provider
- The primary provider acknowledges receipt of the plan
- Defensive Strategy: Acknowledge receipt of information from the specialist
- The primary provider communicates the plan to the patient/family
- Defensive Strategy: Confirm understanding of plan by patient/family; develop care coordination between the primary provider and the specialist
To make this process less time consuming, the American College of Physicians has developed a form to assist you in covering these steps:
If you elect to use a checklist, such as this one referenced, keep a copy of the form in your policies and procedures manual. Date the form as to when you start using it. When it is used for a referral, keep a copy in the patient’s chart so you have documentation that you: (1) made the referral; (2) provided appropriate and essential information needed for the consultation; and (3) set the expectations for the consultant.
Please let us know if we can answer your questions about the referral process.