Physician referral issues causing more out-of-network care

27 Aug 2018 | SOURCE: Healthcare Dive



Dive Brief:

  • Some providers aren’t properly referring patients, which could lead to inappropriate and out-of-network care, according to a new survey by Kyruus.
  • The online survey of 200 primary care and specialty physicians found that 34% of out-of-network referrals could be avoided if providers had more information on other doctors’ specialties and areas of focus.
  • Kyruus found that 77% of providers recognized the importance of keeping patients in-network for care coordination, but 79% admitted that they refer patients out-of-network.

Dive Insight:

Kyruus said the survey shows that improving referral processes can help health systems improve patient retention.

A leading theme in the report is that providers don’t have the information needed to make sure patients are getting clinically appropriate, in-network care. Nearly half of doctors surveyed said they have trouble determining who is in-network. The doctors estimated they could avoid one-third of out-of-network referrals if they had more information about in-network providers.

Another problem that can hurt patient retention is that 42% of patients leave a provider’s office without a necessary referral appointment booked.

A whopping 72% of providers acknowledge that they or their staff usually refer to the same provider for a specialty rather than figuring out whether there’s another provider with more specific expertise or who has an earlier appointment. On the flip side, 42% of providers said they’re not practicing at the top of their license most or all of the time, which the report said can hurt physician satisfaction.

Erin Jospe, chief medical officer at Kyruus, said knowing who’s in-network and their specialties is a long-held challenge for physicians. “This new research reaffirms the widespread need to empower physicians with better insights and capabilities, so they can make the best referrals for their patients and help guide their care more effectively,” she said in a press release.

Beyond care coordination and provider satisfaction, the issue of out-of-network care goes to balance billing, also called surprise billing, and rising out-of-pocket costs. A recent Kaiser Family Foundation report found that nearly 20% of inpatient admissions in large employer health plans include a claim from an out-of-network provider. Those claims are especially problematic for patients getting outpatient mental health services.

Rising out-of-pocket costs are causing Americans to delay healthcare. A recent Bankrate survey of 1,000 adults found that 22% said they or a close family member delayed necessary medical care because of the cost, and 77% said cost worries had led them to avoid care.

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