Executives at health plans including Medicare Advantage (MA) and Medicaid managed care organizations (MCOs) partner with ReferWell to tackle value-based care initiatives for their highest risk, costliest members and help the rest of their members stay healthier. ReferWell provides technology and operational support to close care gaps with less effort. With easily shared clinical data, payers can feel confident that physicians will direct care transitions to the highest quality, lowest cost network providers. And that their members will enjoy a better experience.

Challenges Solved for Health Plans


Drive Care Transitions to the Optimal In-Network Providers

We curate a complete list of your plan's top-tier, highest-quality/lowest-cost specialists so network providers direct members to the appropriate option, personalized to each member's needs and your organization's value-based goals. Filter referral providers by insurance accepted, subspecialty, responsiveness, location and language.


Get Members to Follow Through on Appointments More Often

ReferWell enables referral appointment scheduling at the point-of-care and our care navigators book preventive/care gap appointments at the point of call; the system provides automated reminders, including automated satisfaction follow-up surveys. We're helping plans increase member compliance with recommended care by 60110% across all beneficiaries as they improve the member experience. More referrals get seen. More care gaps get filled. More HRAs get done.

Track & Improve Care Coordination

No more chart chasing! With complete network visibility, track that members completed their appointments and capture the results for the member’s PCP by closing the loop.


Improve the Member Experience

When you take the burden of finding care off of members, you boost satisfaction and retention rates. That translates to higher Star ratings, CAHPS and HEDIS scores and CMS reimbursement. 


“ReferWell is super easy to use and having patients' insurance information and medical records ahead of time makes the whole provider network much more efficient.”

Head of Provider Networks, large payer

Start closing care gaps today.

See how ReferWell impacted 77% of members' care gaps for colorectal cancer screening (COL). Get your copy of the case study now.

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Explore Solutions for Health Plans

Referral Management

Improve member access to specialty care, direct patient movement and see all network activity in real-time.

Care Gap Closure

Improve Star ratings, CAHPS scores and HEDIS measures. Close care gaps and boost satisfaction and outcomes.

Risk Adjustment Performance

Make the most of in-home evaluations and risk assessments, leading to appropriate follow up care.


Increase member access to behavioral health specialists and avoid costly complications.

About Medicare Advantage

Medicare Advantage, also called Medicare Part C, is a health insurance option available to people who are eligible for Medicare (generally those ages 65+). Private insurance companies, or Medicare Advantage organizations, provide these plan options directly to beneficiaries, whereas the Centers for Medicare & Medicaid Services, an agency of the federal government, administers Original Medicare.

About Medicaid Managed Care Organizations

Each US state designs its own Medicaid program in accordance with federal rules. Most states use private health insurance plans known as Medicaid managed care organizations (MCOs) to deliver comprehensive health care to Medicaid beneficiaries on behalf of the state. Those who qualify for Medicaid include low-income individuals, certain pregnant women and children and others as determined by the state.

Like Medicare Advantage plans and accountable care organizations, MCOs accept a set (capitated) per member per month payment for the services they provide and are therefore incentivized to provide the most efficient, highest quality care at the lowest cost.

Quality Matters: Plans Focus on Star Ratings, CAHPS and HEDIS

Under CMS Star Ratings, plans need to achieve four or more stars to receive a five percent bonus payment. Starting this year, the patient experience, access to care and member complaints category are starting to shift from a weight of one to four over the next three years. 

The CAHPS Health Plan Survey — the AHRQ’s measure of member experience — asks members to rate their experience with communication and access to care.

HEDIS, the NCQA’s measure of plan performance, looks at utilization, outcomes, access, experience and more. 

What do all three of these measurements have in common? They require plans to be laser focused on member satisfaction, providing a positive member experience with accessible, high-quality care in order to drive the highest reimbursements and revenue. 

What is HCC Coding and Why Does it Matter? 

Hierarchical Condition Category (HCC) coding is a risk-adjustment model that attempts to estimate the future health care costs of members; it is the model used by CMS to determine risk adjustment payments to health plans.

With accurate HCC coding, plans can target their highest-risk members and most complex cases for the appropriate level of care that will improve health outcomes. Health care technology offers payers the ability to increase network visibility to collect HCC coding, identify high-risk members and efficiently improve their overall health.