Referral Policy

Patient Referrals

NOTE: Primary Care Providers should utilize Signature Healthcare specialists for all initial consultations. Should the service not be available within Signature, the Primary Care Provider should contact the RN Referral Navigators.

PURPOSE:

The success of Signature Medical Group (henceforth SMG) network rests firmly in our ability to deliver to our patients high quality, cost efficient care that meets with the patients expectations; i.e., to achieve the "triple aim". To accomplish this goal, a specific referral guideline which maximizes the benefit of the primary care/specialist interaction and provide patients with coordinated care is recommended. This policy applies to all SMG patients, regardless of insurance.

The Institute of Medicine issued a report on the state of the health care system that included several goals for overhaul: to make the system safe, effective, patient-centered, timely, efficient, and equitable. Appropriate use of the subspecialty care is a key component of these goals.

RESPONSIBILITIES:

It is the policy of SMG as an integrated healthcare system to provide a continuum of care for patients, which meets both their acute and ambulatory needs. SMG is responsible for providing an efficient means of communication for every patient served.

It is the responsibility of all associates to ensure adherence to and compliance with these policies and procedures for the timely provision of services to patients requiring specialty referrals.

BACKGROUND:

Signature Healthcare provides high quality, low cost integrated care and is dependent on managing its populations within this integrated system to maintain both its mission to the community and its financial viability.

Signature Healthcare is increasingly responsible for the quality and cost of care for populations of patients inside of Medicare, Medicaid and commercial contracts. Most of the contracts contain similar language in defining networks, referral processes, the role of the PCP, and the appeals rights of patients. None of these contracts explicitly state that the patient has the obligation to seek their care within the network nor are they specifically restricted to subsets of providers within the network (except TMP).

Based on these factors Signature Healthcare endorses a strategy to retain patients within the network based on a defined set of criteria including availability of specialties of demonstrated high quality and reliable access which are dependent on coordinated care to provide excellent results. This applies to patients who are not currently under the active care of a non-SMG specialist.

For patients requiring community level specialty care (that can be provided by SMG specialists) within the definitions of prior history and continuity as defined below and in the specialties of Hematology/Oncology, Orthopedics including Spine, Cardiology, Endocrinology, Podiatry, Weight loss/Bariatrics, Rheumatology, Dermatological Surgery and General/Vascular surgery, referrals will follow the following algorithm:

> Patient must have seen the PCP within the last year
> Patient must have seen the SMG specialist first.

If either of these conditions are not met then a referral will not be processed. If the patient meets both conditions and still requests an external specialist the patient will be given a referral to Beth Israel Deaconess Medical Center (BIDMC) provided the service is available. An exception will be for patients with an oncologic diagnosis for which a second opinion will be allowed with any outside specialist. For patients who refuse either approved SMG specialists or BIDMC, no referral will be issued and the patient will be provided the opportunity to appeal to the internal Appeals Process, their insurance carrier or to change their PCP. Exceptions to the algorithm will be allowed on the basis of previous clinical history, these have been further defined in sub-sections below. A Referral Navigator will play a role in assisting in communications with patients about the advantages of in-network specialty care. The navigator will also coordinate all diagnostic studies at SHC prior to tertiary referrals.

POLICY:

GENERAL REQUIREMENTS:

1. This Policy supersedes any previous Referral Policy for SMG or BGPMA.
2. All referrals regardless of payer will be entered into the referral module this includes referrals generated by specialists.
3. Regular Referral Pathway: All patients requesting Specialty referral will have seen their primary care physician (PCP) within one year. Requests for referrals will not be authorized if the PCP has not seen the patient within this timeline. An exception for urgent conditions will be made on a case-by-case basis.
4. Lateral referrals within academic medical centers, specialty to specialty, will NOT be allowed; all such requests will be directed into the regular referral pathway.
5. Referrals from an outside office to a community based specialty will be redirected to within the SMG network. Referral navigator should be involved in all re-direction.
6. No retroactive referrals will be processed, with the exception of Urgent Care on weekends/holidays if PCP is not available
7. The referral navigator will coordinate Referrals to outside specialists to ensure work up is completed at SHC and sent with patient
8. Referring provider is responsible to review outside consultants notes and ensure no downstream leakage

REQUIREMENTS FOR 10 CORE SPECIALITIES OF ORTHOPEDICS including Spine, GENERAL AND VASCULAR SURGERY, HEMATOLOGY AND ONCOLOGY, CARDIOLOGY, ENDOCRINOLOGY, Dermatologic Surgery, Optometry/Ophthalmology including Retina), Weight loss/Bariatrics, Rheumatology & Podiatry:

SMG has invested significant resources into the following core specialties and monitors quality and access for the following Cores:

ORTHOPEDICS including Spine, GENERAL AND VASCULAR SURGERY, HEMATOLOGY AND ONCOLOGY, CARDIOLOGY, ENDOCRINOLOGY, Dermatologic Surgery, Optometry/Ophthalmology including Retina, Weight loss/Bariatrics, Rheumatology & Podiatry:

9. In these specialties, the following Core 10 Specialty Pathway will apply: The patient must have been seen by the SMG specialist for the initial visit. A second opinion may be referred externally, for one visit only, to Beth Israel Deaconess Medical Center. Transfer of care will be allowed after a second opinion is reviewed by the Referral Leakage committee and determined to be appropriate for tertiary care. SHC will work with the tertiary facility to encourage community-level care that can be provided in the community to be kept in the community.
   1. Orthopedics:
      1. If the patient calls from the office of a non-SMG orthopedic physician: a same-day re-direct appointment with SMG will be pursued. If no same- day appointment is available, the patient will be provided a referral for a single visit to the non-SMG physician. All future visits will be decided by the PCP after determining need for additional specialty care.
      2. For a new clinical concern: If patient has not been under the care of a non-SMG orthopedic doctor for 9 months, the Core Specialty Pathway will be followed. If the patient has been under the care of non-SMG orthopedic physicians within the prior 9 months, the external referral will be allowed for any clinical concern with that specific Ortho diagnosis. For any NEW diagnosis patient will need re-direction.
      3. For the same clinical problem or post clinical intervention: The patient will be allowed an external referral for any period of time.
   2. General and Vascular Surgery:
      1. If the patient is presenting with a problem for which they were under the care of a non-SMG physician, regardless of the period of time, the patient will be provided an external referral to the same specialist or group. If the patient is presenting with a new problem, the Core Specialty Referral Pathway will be applied.
   3. Hematology and Oncology:
      1. For a new diagnosis of cancer, or hematologic question, the patient must see an SMG oncologist first. A second opinion consult will be allowed as needed thereafter but only to a specialist at the BIDMC, or at BMC for ACO patients. A patient may go outside SMG/BIDMC/BMC for their care only if BIDMC/BMC does not provide a required cancer service. CMO approval of a referral to a non-BIDMC tertiary center for an evaluation/care will be preceded by a discussion of the case between the CMO and the Chief of Oncology.
      2. If a patient has a recurrence of their cancer, and has not been seen by their previous oncologist within two years, the Core Pathway will be followed
   4. Endocrinology:
      1. If the patient has not been seen in the past year by an external endocrinologist, then the Core 11 Specialty Pathway will apply.
   5. Cardiology:
      1. Pursuant to January 2018 letter sent to all SMG, All Signature Medical Group/Signature Healthcare patients are required to see a Signature Medical Group Cardiologist.
         (See Chart at bottom)
10. Role of a Referral Navigator:
    1. Referral Navigator is required to have clinical experience as a nurse and will serve as a resource for the PCP in redirecting patients to appropriate SMG Specialist.
    2. Will be involved in assisting with communications with patients regarding the advantages of in-network referrals.
    3. Will be involved in situations in which the above exceptions to out-of-network referrals are not met and the patient still requests an out-of-network referral. The referral navigator’s participation in this process will be requested by the PCP.
    4. Will maintain regular and direct communications with the PCP as pertinent to the referral that is being processed.
    5. Will communicate with SMG VP of Quality and subsequently with Referral Leakage Committee in situations that require clinical questions or concerns that need to be addressed.
    6. The Referral Leakage Committee will have at least 3 Providers in attendance to support Referral Navigator in case reviews
    7. Appeals data will be tracked and reported quarterly to the Health Policy Committee.
    8. Track core specialty leakage and escalate concerns with any Core not meeting target for leakage
    9. Provide quarterly reports to SMG Quality with leakage data on all Core Specialties.
11. PCPs will continue to evaluate referrals requests for long term management of stable chronic care conditions with outside specialists to determine if this care can now be managed by the PCP or internal specialist.
12. Department Chiefs will share unblinded data within their departments. The data will include PCP practice patterns for referral management, in comparison with their peers. Chiefs will begin to discuss these results at monthly meetings in an effort to begin to understand and address the significant, unexplained differences in treatment patterns revealed in the data.
13. All TMP patients must use SMG specialty for all available care. Requests to go out of network will be denied and the patient encouraged to call Tufts Health Plan to file an appeal. This is a CMS mandate.
14. PCPs will continue to evaluate referrals requests for long term management of stable chronic care conditions with outside specialists to determine if this care can now be managed by the PCP or internal specialist.