Source: https://ensurecare.ai/blog/half-of-referrals-never-close-the-loop > About half of specialist referrals are never completed. Track each one until the specialist reports back, and fix prior authorization problems before the visit. Referrals # Half of referrals never close the loop. Then comes the friction. About half of specialist referrals are never completed. Track each one until the specialist reports back, and fix prior authorization problems before the visit. By [EnsureCare Team](https://ensurecare.ai/about). August 10, 2026. 3 min read ## TL;DR **The gap** By a common estimate, about half of specialist referrals are never completed. Most EHRs record that someone placed the order, and nobody tracks the referral after that. **What closing it looks like** Track each referral until the specialist reports back, and fix prior authorization problems before the visit instead of appealing denials afterward. [See how referral closure works](https://ensurecare.ai/modules/referral-closure) A referral starts when a clinician sees that a patient needs specialty care and orders it. After that, nobody may own the referral until the patient sees the specialist. A [patient safety guide from IHI and the National Patient Safety Foundation](https://www.ihi.org/resources/publications/closing-loop-guide-safer-ambulatory-referrals-ehr-era) estimates that more than 100 million specialist referrals are requested in the US each year, and only about half are completed. When a referral breaks, the patient’s diagnosis and treatment can be delayed. ## Most referrals stall before anyone books the visit When [Duke Health researchers](https://doi.org/10.1007/s11606-018-4392-z) followed a year of primary care referrals to 20 specialties, only about a third ended in a documented specialist visit. The biggest gap came before scheduling, because more than a third of the referrals never got an appointment date. Referrals with longer waits and longer drives were less likely to be completed. What happened to 103,737 primary care referrals 1. Never got an appointment date**38.9%** 2. Ended in a documented visit**34.8%** 3. Got a date, but no documented visit**26.3%** Percent of referral scheduling attempts from Duke primary care to 20 specialties, July 2015 to June 2016. The last row is what remains after the first two. Source: Patel et al., Journal of General Internal Medicine, 2018. Specialist match, cardiology Who can see Maria within 14 days? Best fit Specialist Network Distance First opening Summit Heart Clinic Out of network3 miles This week Valley Cardiology In network22 miles In 6 weeks Lakeside Cardiology In network4 miles This week Illustrative patient scenario. In our experience, most EHR referral modules record that someone placed the order and stop there. Nobody tracks the referral through scheduling, payer approval, outreach to the patient, and the specialist’s report back, so nobody is accountable when the patient never gets care. When the patient goes out of network instead, the health system also loses the revenue. ## Prior authorization is an early sign of missed care A referral that gets scheduled often waits on prior authorization next. In an [AMA survey of physicians](https://www.ama-assn.org/press-center/ama-press-releases/ama-survey-prior-authorization-reform-pledge-falls-short-physicians), 95% said prior authorization delays access to care, and nearly four in five said patients abandon treatment because of it. When the authorization isn’t ready, the visit gets pushed back. When the documentation is incomplete, the payer denies the claim after the care is delivered. Health systems can prevent many of these denials before the visit instead of appealing them afterward. Prevention starts when the order is placed: check whether the payer requires authorization, find out what clinical evidence it needs, and confirm the order and diagnosis are complete before submission. After that, watch the status of each request, and flag claims that are likely to be denied before they go out. Payer requirements, knee MRI What does the payer need before Monday? Gap found Requirement In the chart Status MRI order Signed by Dr. Lee Order on file Met Clinical note Supports the order Visit note Met Physical therapy6 weeks documented Not found Missing Illustrative patient scenario. **Good to know** Under the [CMS Interoperability and Prior Authorization Final Rule](https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f), Medicare Advantage, Medicaid, CHIP, and ACA exchange plans must decide urgent requests within 72 hours and standard requests within 7 days, and they must give a specific reason for each denial. By January 1, 2027, the same plans must also accept prior authorization requests electronically through FHIR APIs, a standard way for systems to exchange health data. ## How EnsureCare closes the gap Estimate the impact with your own numbers. [Check your numbers](https://ensurecare.ai/roi?useCase=referrals) 1. 01. **Predict** Flag referrals that have no appointment date or are waiting on authorization. 2. 02. **Prevent** Find what each referral is waiting on, and clear it before the visit. 3. **Protect** Confirm the visit happened and the specialist reported back. ## Count a referral as done when the specialist reports back We count a referral as complete when the specialist accepts it, the patient is scheduled and attends, and the specialist reports back to the referring clinician. We track time to schedule, completion rate, out-of-network referrals, and how often consult notes come back. A count of referrals created only shows how many orders went out. Ask your team how many of last quarter’s referrals never got an appointment date, and who was responsible for following up on each one. Share this article FAQ ## Questions on this topic. ### Why do referrals stall? Most referrals stall before anyone books the visit. In one large health system, more than a third of primary care referrals never got an appointment date. Other referrals wait on prior authorization, on a patient that staff can’t reach, or on a specialist with no open slots, and most EHRs don’t track the referral after the order. ### Why treat prior authorization as a care problem? When the authorization isn’t ready, the visit gets pushed back and the patient waits longer for care. In an AMA survey, 95% of physicians said prior authorization delays access to care. When the documentation is incomplete, the payer denies the claim after the care is delivered. ### When is a referral closed? A referral is closed when the specialist accepts it, the patient is scheduled and attends, and the specialist reports back to the referring clinician. A count of referrals created only shows how many orders went out. ## More from the blog [See all articles](https://ensurecare.ai/blog) - [Agentic AI **Care Adherence: The unaddressed gap** Clinics already know where patients fall out of care. An agentic AI workforce does the follow-up work on each case, and staff make every judgment call. Read the article](https://ensurecare.ai/blog/care-adherence-the-unaddressed-gap) - [No-shows **Why patient no-shows are a coordination failure** We keep treating a coordination problem like a messaging problem. Patients miss visits because something gets in the way, and another reminder doesn’t fix it. Read the article](https://ensurecare.ai/blog/why-patient-no-shows-are-a-coordination-failure) - [Readmissions **Discharge is a handoff, not a finish line** A readmission risk score helps only when someone carries out the discharge plan. Patients who see a clinician within 30 days are readmitted less often. Read the article](https://ensurecare.ai/blog/discharge-is-a-handoff-not-a-finish-line) ## Bring us one care gap. Let’s close it together. Pick an area where your team schedules care but patients struggle to receive it. Join us for a 30-minute walkthrough to see how EnsureCare can close that gap in your care setting. EnsureCare [Book a demo](https://ensurecare.ai/book-demo) [Run your ROI numbers](https://ensurecare.ai/roi) Buy through your cloud marketplace - [Available in AWS Marketplace](https://aws.amazon.com/marketplace/pp/prodview-y62fqi76k4iee)