OVERVIEW
Health systems and medical groups have become increasingly sophisticated in understanding who is referring patients—but far less clear on where those patients ultimately go and what clinical services they actually receive once they arrive. While most organizations can see primary care–to–specialist referral patterns, that visibility typically stops at the provider level, leaving a critical blind spot in understanding downstream utilization by organization, facility type, and clinical service.
As a result, leaders know that patients are flowing out of network—but not whether those referrals translate into high‑value procedures, routine diagnostics, or services that could (and should) be retained.
Today’s referral analytics, including HSG’s existing PCP → Specialist flow views, highlight directional movement without the clinical context needed to act. A gastroenterology referral, for example, may result in a colonoscopy at an ASC, an endoscopy at a hospital outpatient department, or no procedure at all—but those distinctions matter. The downstream impact is meaningful: missed revenue capture, misaligned growth strategies, suboptimal patient access, and weaker physician alignment—all driven by an incomplete picture of how referrals truly convert into care.
Provider‑to‑Organization Tracking closes the gap by connecting referrers to receiving organizations and the services delivered, turning referral data into actionable intelligence that health systems can finally use to drive targeted growth, smarter network design, and coordinated marketing and referral management across the right service lines, at the right organizations.
CHALLENGES
Without service‑level insight, organizations struggle to:
- Identify leakage/keepage at the service line level,
- Align physician outreach and network design with actual procedural and condition‑based pathways,
- Optimize site‑of‑care strategy and capacity as volumes shift across settings, and
- Coordinate marketing and referral management to the right service lines at the right organizations.
Client should assess if they can analyze:
- By service line, which organizations are being used by key referrers today,
- Where patients receive specific procedures after an in network visit, and
- Quantifiable data around leakage by service line and facility type.
APPROACH
HSG’s Insights to Action Methodology takes clients through six key steps to identify problems and create long-lasting solutions.
DATA ACQUISITION
What data do we aggregate to solve the problem?
HSG provides both commercial and Medicare FFS claims data to drive analyses. Clients’ provider master and service line taxonomies are used to tailor analytics and streamline internal reporting/analysis.
DATA TRANSFORMATION
How do we extract information from the data?
- NPI Mapping and Normalization
- Clean and standardize NPIs, organization names; group facilities to health system parents.
- Build provider -> organization mappings for easier analytics
- Service Line Mapping
- Map CPT/HCPCS/ICD to HSG Service Lines → Sublines → Procedures (e.g., GI → Endoscopy → Colonoscopy).
- Quality Checks
- Suppression of low values (noise) and outliers
PROFESSIONAL SERVICES
What expertise do we apply to find a solution?
- Network Design & Leakage Mitigation: Prioritize organizations and service lines for preferred pathways and alignment.
- Physician Alignment & Outreach: Identify PCPs/specialists with divergent patterns; help craft data-driven outreach talking points by service line.
- Operations & capacity: Match observed demand to clinic/procedural capacity, recommend capacity additions or shifts to ASC.
PACKAGING
How do we structure and apply our expertise?
- Assessment and Recommendations, including a Market Workbook to:
- Show provider to organization patient flows by service line
- Establish baseline KPIs, and
- Clearly surface priority opportunities—such as identifying GI colonoscopies leaking to a competing health system from a defined set of PCPs.
- Implementation Support to help our partners:
- Design preferred referral pathways,
- Address access and scheduling gaps, pilot operational changes, and
- Support targeted provider outreach.
- Monitoring Plan with quarterly data refreshes and trend dashboards to track progress against defined goals.
DELIVERY
When and how do you receive solutions?
- Data and insights are delivered through HSG Dashboard along with other related claims-enhanced data solutions and Workbooks.
- Data updates are delivered on a quarterly basis, and resulting insights and growth plans are typically incorporated into our quarterly reporting cadence with the organization’s executive teams.
IMPLEMENTATION & MONITORING
How do we provide ongoing support to your organization?
HSG prioritizes monitoring the following measures to drive positive momentum in targeted service lines:
- Leakage rate (% of attributed encounters leaving aligned organizations).
- Keepage rate and market share by site of care (ASC vs. HOPD vs. IP).
Results are reviewed on a monthly operations review; quarterly executive updates; and through an annual strategy refresh. HSG also drives growth through initiatives like:
- Developing a physician outreach plan: Prioritized PCP/specialist lists with talking points by observed flow gaps.
- PRM Integration (where applicable): Loading insights into client’s PRM of choice to help make insights actionable by boots on the ground staff.
RELATED CONCERNS
While executing this analysis, Workbook can surface adjacent opportunities:
- Access & scheduling redesign for high demand service lines.
- ASC strategy (migration roadmap for appropriate procedures).
- Physician compensation alignment to pathway adherence and access goals.
- Network integrity review for narrow networks and tiered benefit designs.
Ready to dive deeper into your data and get a clearer picture about your Patient and Provider behaviors? Reach out to DJ Sullivan at [email protected] to discuss and see if this solution could be a good fit for you.
