Managing Referral Relationships

When the physicians at Freedman Memorial Cardiology in Alexandria, La., start to see a dip in the number of referrals they’re getting, they know it’s time to get out of the office. Most of Freedman’s referrals come from physicians they run into at the hospital, but they also see patients from primary-care physicians practicing in offices in the surrounding rural towns - doctors they rarely see in person.

So office coordinator and nurse manager Dale DeWitt arranges site visits. “You’ve got to remind them you’re there,” she says. Otherwise, it can become “out of sight, out of mind.”

Freedman’s periodic visits help build and maintain their referral base, keeping referring doctors happy and the patients coming. For both referring physicians and specialists, relationship management is vital to a thriving practice. Of course you’re busy, but managing referral relationships “does not have to be difficult,” says Ken Hertz, a consultant with the Medical Group Management Association. A few small gestures - a note, a call, a brief visit - can make a big difference, and you’ll be glad you took the time. “None of this is brain surgery,” says Hertz.

Network, network, network

Physicians are scientists - not always natural extroverts. Even just the idea of getting out of the office to network with other physicians makes many doctors cringe and hide behind the exam room door. “I find most physicians hate to do it,” says Susanne Madden, founder of The Verden Group, a managed-care-focused consulting firm. “They hate to get out there and introduce themselves.”

But without seizing opportunities to meet other doctors, you could find your referral pool slowly drying up, or, if you’re in primary care, find it harder to manage your patients.

Madden encourages doctors, especially those who are new in town and trying to establish a referral base, to introduce themselves and ask fellow colleagues to introduce them to other physicians.

Freedman physicians usually stop by referring physicians’ offices around lunch time, even if for just 15 minutes. They may have lunch at the office or dine at a spot down the street. This gives them some time to meet, talk, and remind their colleagues of - or introduce them to - the services Freedman has to offer. They can learn the names of staff members and ask if the referring physician is having any troubles sending them patients.

It’s a habit the physicians started when they opened the practice six years ago. Now, the doctors make a point to visit referring offices at least once a year, and when referrals start to wane, or just to meet new doctors in town.

Community events and lectures can also provide a forum for some handshaking. For new physicians, be prepared with the “elevator speech,” Madden recommends, a short, quick description of who you are and what you do. “Refine that message to a couple of sentences.”

Pediatrician Cameo Carter knows a thing or two about networking. Last November, she was the new kid in town in Redlands, Calif., launching a small practice in an area saturated with well-known large group practices. She knew she’d have to work hard to get her name out and differentiate herself as a small practice dedicated to excellent customer service.

Knowing OB/GYNs would be a primary referral source for new patients, Carter started with her own physician, then branched out, calling OB/GYNs in the area and stopping by their offices to say hi and make her pitch. She also made sure to shake hands with all the staff, including the receptionists and nurses. “They were really happy to talk with me between patients for a couple minutes,” says Carter. Later, she gave the physicians a flier advertising her practice that they could slip into their new mother welcome kits. And it worked. Each time she would visit an OB/GYN, she’d see a bump in new patients the next week.

Insurance companies can represent another potential referral source, especially for new-in-town physicians. Madden suggests getting in touch with your payers to tell them what services you offer. Next time they get a request for authorization for an out-of-network physician, they may be inclined to direct patients to you instead, says Madden.

That extra step

Referrers and specialists both have to manage referral relationships, but in different ways. Although both should start by networking and nurturing strong communication, there are a few other protocols specialists and other referred-to physicians should keep in mind:

Be accessible. Make it easy for physicians to direct patients to you. Try providing referring physicians with any necessary forms or information sheets, including maps, phone numbers, or office hours, says Hertz. Even details about your practice and its physicians should be at referring doctors’ fingertips. “Look how easy it is to say, ‘Here’s a map, here’s [information] about the practice and how to reach them,’” says Hertz. You may also consider holding a seminar on a topic relevant to your primary-care buddies, and have a few brochures from your practice handy.

Send a thank-you note. “If you are a physician that has been referred to, the quickest way to cut off referrals is to not send thank-you notes or follow up reports,” says Madden. A short, handwritten note thanking the referring physician for the patient can go a long way to cementing that relationship. Jeffery Denning, a consultant in La Jolla, Calif., recommends taking it one step further, and pick up the phone - the same day - to say thanks. Ask the referring physician if he wants a call for each referral, and even if he insists that isn’t necessary, call again anyway, Denning says. “Just do it anyway, and be very candid. ‘I need all the help I can get; bless your heart,’” he suggests. Then follow up the call with a note. Denning recommends practices systematize writing the thank-you note by putting a stamped envelope on a new patient’s chart as a reminder.

Just like any other doctor, Carter quickly sees her schedule get out of hand, so she makes sure to put this step on her schedule. “I will let it go if I don’t put it in,” she says. “This is the 30 minutes I am going to use to write thank-you notes.”

Report back as soon as possible. After receiving a referral, the physicians at Freedman do their best to squeeze the referred patient in that day or that week, and report back to the referring physician as quickly as possible. “Prompt communication, prompt consult letters, prompt discharge letters,” recommends DeWitt. “It’s still all based on communication. That’s how we have to work together.” Don’t forget to address the specific need for which the patient was referred in the first place - not just a generic exam, please - and get the report back to the referring physician right away. No referring primary-care physician wants to waste time and energy tracking down that report, and any delay could be a strike against your referral relationship.

Ask how you’re doing? Consider taking some time to briefly survey the referring physicians, says Hertz. Once a year or two, send a quick questionnaire asking how your office is doing. Can the referring physician get through to your office easily? Are you getting the reports back on a timely basis? “You have to ensure that the doctors that have been referring to you are continuing to refer to you,” advises Hertz. “And if they are not, you need to find out why.” Or borrow a move from Freedman’s playbook and plan regular meetings with referring physicians to find out what the problems may be or just remind them that you’re there and are ready to take patients.

Although it may sound as though specialists are the only ones bearing the referral relationship burden, think again. Primary-care physicians and other referrers aren’t off the hook. You, too, should feel comfortable with the specialists treating your patients, Madden says. Think about it from the patient’s perspective: “If your doctor refers you to someone who you have a bad experience with, your own doctor is tarred with the same brush,” she says.

Christopher Ogburn, a family physician at Prime Care Family Practice in Colonial Heights, Va., says that a professional relationship is important, because “it improves the quality of communication between the consultant and myself, and that leads to better patient care in the long term.” To avoid a tarnishing encounter, here are few things referring docs should remember:

Be clear on your needs. You are referring a patient to another physician for a specific reason, such as a test or an opinion, so make sure the specialist knows why he is seeing the patient. “It’s frustrating to send a patient for one thing, and you get an office note or a letter back and they addressed something that was already being taken care of, and they didn’t even address the main reason you sent them,” Ogburn says.

You also want to make sure the specialist understands you aren’t transferring care entirely to him. A family physician might rely on an internist’s expertise regarding a patient with lupus, Denning says, but the internist shouldn’t mistake the referral of lupus as a referral of primary care. DeWitt agrees that specialists should know to send the patient back to his primary-care physician. “We see them on six months or annual basis, instead of keeping them as our patients. We are trying to just treat their cardiology problem.”

Listen to your patients. It’s up to you to make sure you’ve sent your patient to a specialist you trust and respect - and that your patient has a pleasant experience. The best way to know? Just ask. “Listen carefully to patients when they come back from a referral for any feedback,” recommends Denning. “If it doesn’t go well, alert the specialist.”

Stand out by being nice

In the end, whether you’re the referring physician or the one being referred to, simply being nice will serve you well. Aim to be everyone’s favorite, the friendliest, the most accommodating. And pass that feel-good vibe on to the staff as well, encouraging your front desk staffer to use her name when she answers the phone or even write a thank you letter of her own to express appreciation for a referral or a kind interaction.

Remember, it’s nice to be smart, but it’s smart to be nice. The notes, calls, and surveys are simple steps to smooth the referral relationships, but not all physicians take them, so it’s easy to stand out. Make these extra steps a priority or part of the daily routine and you’ll see it pay off. “All we want to do as people,” says Hertz, “is feel appreciated and feel recognized.”

Sara Michael is associate editor of Physicians Practice. She can be reached at sara.michael@cmpmedica.com.

This article originally appeared in the September 2009 issue of Physicians Practice.