Leakage and Referrals Explorer

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Product Overview

Leakage and Referrals is an analytic tool to support more effective network management. The tool is designed to help health care organizations evaluate referral patterns and out-of-network service utilization to identify opportunities for more effectively managing their networks.

Features

  • Summary: Summary level view highlights key trends in network performance, including leakage PMPM and referral trends
  • Leakage: Evaluate out-of-network service utilization, considering the total dollars going out of network by provider, facility, procedure, and geography
  • Referrals: Evaluate in and out of network referrals by specialty, procedure, and facility over time; in addition to primary referral patterns, consider chain leakage to identify additional opportunities for improvement

Benefits

Easily evaluate out-of-network service utilization and referral patterns

  • Quickly evaluate key statistics regarding overall provider network health
  • Drill into out-of-network service utilization (leakage), identifying opportunities to better control costs and reduce overall PMPM payments for at-risk contracts
  • Evaluate the appropriateness of referral patterns and opportunities for improvement

Faster time to value for cross-continuum data analysis

  • Claims-based dashboard provides a view across the continuum of care
  • Eliminate the burden of manually scrubbing and analyzing claims-based files
  • Ongoing claims-based files refreshed as quickly as 24 hours upon receipt

Measures

Leakage

  • Total dollars leaked and % of dollars leaked
  • Leakage from PCPs, by zip code
  • Leakage by facility type, procedure, and geography

Referrals

  • Total referrals
  • In and out-of-network referrals
  • Network referrals by specialty
  • Referrals over time by specialty

See Sample Screenshots of Leakage and Referrals Explorer

Data Sources

  • Claims data (leakage) - Required
  • EMR data (referrals) - Required

Leakage and Referral Explorer: A Deeper View

Background

To succeed under at-risk contracts, ACOs need to successfully manage care across the continuum, including services that attributed patients receive in and out of the network. In addition to building an adequate physician network, health care organizations must effectively manage the network that they have in place by reducing out-of-network service utilization and ensuring appropriate referral patterns.

What types of problems does Leakage and Referrals Explorer address?

ACOs lack actionable information about how to better manage their physician networks, a critical competency to succeed under at-risk contracts. Even when ACOs gain access to claims data, they may lack the expertise or resources to conduct regular analyses and identify opportunities for improvement.

Use Case

A health system enters a shared-savings agreement with a local payer, and wants to understand how it is performing against its per-member-per-month targets. Using ACO Explorer, the executive team can quickly see that for the past three months PMPM payments trended below the target, but that there has been a worrisome rise in spend in the last month. The amount of payments to out-of-network providers is also on the rise. Using Leakage and Referrals, analysts evaluate out-of-network service utilization and referral patterns. Based on this analysis, the team identifies several physician practices to target with education on referral best practices.

Anticipated Improvements

  • Reduce costs, reduce leakage, improve referral patterns

Success Measures

Opportunity Identification:

  • Identify potential savings from improving in-network referral rates
  • Targeted education efforts result in 25 percent more referrals to in-network providers
  • Leakage and referral improvement efforts lead to an overall reduction in PMPM of 5 percent %