Referral Requests Toolkit
Save money, reduce tedium, and improve service with electronic referral requests
How much time and money does your practice devote to manually asking payers to approve referrals to other physicians, hospitals and other health facilities? How much time does your staff spend on the phone with payers, faxing referrals and filling out forms? If your answer is “too much,” electronic referrals may be the solution. By adopting this method, your practice can:
- Save thousands of dollars per physician every year
- Submit referrals and document responses more quickly and accurately
- Provide faster, more convenient service for your patients
- Apply your staff’s valuable time and energy to revenue-enhancing activities
Cost of paper referral requests: $8.30 x 1,000 = $8,300
Cost of EDI referral authorization: $2.07 x 1,000 = $2,070
Average annual savings from referral request automation per physician: ≈$6,230*
* Based on an annual average of 1,000 electronic referrals submitted for a single physician. Source: Milliman, Inc., “Electronic Transaction Savings Opportunities for Physician Practices.” Technology and Operations Solutions. Revised: Jan. 2006
Calculate your potential savings: View Aetna’s EDI savings calculator
By eliminating significant parts of the manual processes in an office’s routine, physicians can free their practice staff to perform other revenue-enhancing functions. Access the following educational resources “Information technology solutions: consider the potential savings” and determine your practice’s potential savings.
Access the AMA resource “Understanding the HIPAA standard transactions: The HIPAA Transaction and Code Set rule” for an overview of electronic healthcare transactions.
- Beyond the Claim: HIPAA 5010 Administrative Simplification Opportunities to Positively Impact your Revenue Cycle Management
- The "underutilized" transaction that can streamline your referral and prior authorization processes
Take the brief Health Insurance Portability and Accountability Act (HIPAA) Transaction Code Set Vendor Survey to easily find out whether your vendors can process electronic claims and other healthcare transactions.
Visit 5010 electronic administrative transactions for more information on assessing 5010 readiness.
“Considerations for processing electronic transactions in the physician practice” offers specific scenarios of how your practice might adopt electronic claims submissions, and provides additional considerations for your specific situation.
Visit www.ama-assn.org/go/payerpolicies to access online resources from health insurers to help you move towards practice automation.
The suite of electronic health care transactions are designed to work together to create greater efficiencies for both physicians and health insurers. By adopting an integrated approach to using the electronic health care transactions, information gained from one transaction becomes useful information in the next transaction.
- Did you know that the increased use of electronic health care transactions in your practice, such as the electronic eligibility benefit inquiry and response transactions, has the potential to save physicians and health insurers nearly $30 billion per year? 
Access this case study to learn more about the savings your practice can experience using electronic health care transactions.
 U.S. Healthcare Efficiency Index, www.ushealthcareindex.com
“Questions to ask a health insurer before enrolling in an electronic transactions program” outlines key issues with using electronic claims submissions that you need to carefully consider.
“Questions to ask a billing service before enrolling in an electronic transactions program” provides key questions to discuss with your billing service to understand how it can assist you in using electronic claims submissions.
“Questions to ask a clearinghouse before enrolling in an electronic transactions program” provides key questions to discuss whether your clearinghouse provides satisfactory functionality for electronic claims submissions.
Use the Health Insurance Portability and Accountability Act (HIPAA) complaint form to inform the AMA about health insurers and other payers that are out of compliance with the HIPAA electronic transaction and code set standards.