Drive High-Value Referrals & Minimize Leakage

Inappropriate specialty referrals cost health plans billions of dollars annually and negatively impact member experience. These referrals often involve unnecessary consultations and high-cost specialists while leading to cascades of low-value care.

Additionally, evidence suggests that approximately one-quarter of physician referrals in the United States are directed to out-of-network specialists, leading to significant costs for health systems and medical providers. This “referral leakage” occurs when patients are referred to or seek care from out-of-network physicians, impairing care coordination efforts and driving up the cost of care.

Each out-of-network referral, also referred to as instances of “network leakage,” can be costly. Estimates suggest that the financial impact per physician ranges from $821,000 to $971,000, with organizational losses between $200 million and $500 million annually.

Enhancing provider network integrity and optimizing referral patterns is a highly effective strategy to increase in-network utilization while also improving value. However, achieving this requires advanced analytics and the right insights to evaluate and refine referral patterns alongside provider performance.

Understanding the scope and nature of the problem is a critical first step. Insurance claims data provides valuable insights into patient journeys and referral patterns, highlighting the use of out-of-network specialists, hospitals, labs, and urgent care services.

HealthCorum supports organizations with referral opportunity analysis delivered alongside specialist benchmarks on cost, quality, and efficiency. Our proprietary referral identification technology leverages insurance claims data to track patient flow and communication between primary care and specialty providers. With this data, health systems, independent practices, and accountable care organizations (ACOs) can identify which services are being utilized and develop targeted strategies to reduce unnecessary spending.