Outbound referral coordination
Outbound referrals from primary care to external specialists were handled by hand: faxing packets, calling to confirm receipt, chasing consult notes and tracking status.
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Case study
How a 100-provider FQHC automated referral and care gap coordination.
Aunt Martha's Health & Wellness runs referral coordination, care gap closure and voice AI with Linear Health across its network, integrated with athenahealth.
4 wksFirst workflow live
- Organization
- Aunt Martha's Health & Wellness
- Type
- FQHC
- Size
- 100+ providers, 20+ locations
- Location
- Chicago metropolitan area
The challenge
Two coordination crises, one breaking point.
Aunt Martha’s is a community health organization in the Chicago area, with more than 100 providers across more than 20 locations. It faced two coordination challenges:
Care gap closure
Managed care payer files were worked by hand: calling patients, scheduling appointments and closing gaps before payer deadlines.
Care gaps went unaddressed for weeks
Staff couldn't process MCO files fast enough to identify and act on them before the next reporting cycle.
Billing discrepancies caused false flags
Coordinators wasted time chasing care gaps that didn't actually exist.
Referral leakage was significant
Patients referred to specialty care or flagged for preventive screenings were falling through the cracks.
Payer quality metrics were at risk
The ability to close care gaps on time directly impacted reimbursement rates and contract renewals.
Staff burnout was accelerating
Coordinators spent their days on repetitive data entry rather than complex care coordination.
The solution
Two problems, two targeted solutions.
Integrated directly with athenahealth, replacing manual workflows end to end.
Solution for Outbound Referral Coordination
End-to-End Referral Automation
Outbound referrals from primary care to external specialists are now processed automatically. Linear's AI handles specialty matching using a custom CMS-verified provider database, generates and delivers fax packets, follows up with specialist clinics via AI voice agent, and tracks status in real time.
Automated Patient Outreach & Scheduling
Patients are contacted automatically via SMS, email, and voice AI in English and Spanish. Patients can self-schedule or be booked by AI based on provider availability, location, and insurance.
Result: coordinators oversee the automated workflow and handle the exceptions.
Solution for Care Gap Closure
MCO File Ingestion & Gap Identification
Linear Health's AI ingests multiple managed care payer files in bulk, automatically cross-referencing care gap data against patient records in athenahealth. The system validates each gap, identifies billing discrepancies causing false flags, and surfaces only actionable care gaps.
Automated Gap Closure Outreach
Payer patient records are processed automatically. The system contacts patients via their preferred channel, schedules appointments for preventive screenings and follow-ups, and tracks closure status in real time against payer deadlines.
Result: coordinators oversee the automated workflow and handle the exceptions.
Shared Infrastructure
Payer Portal Integration
Linear Health operates across athenahealth and multiple payer portals simultaneously, eliminating the need for staff to log into separate systems to track referral status, authorization approvals, or care gap closures.
The results
How the workflow changed.
What changed after go-live.
| Metric | Before | After |
|---|---|---|
| Patient contact | Manual calls | SMS, email and voice AI in English and Spanish |
| Care gap identification | Manual, batch monthly | Automated, continuous |
| False flag resolution | Manual investigation | Automated detection |
| EHR integration | Manual data entry | Bi-directional sync |
Services deployed
Linear Health platform.
- Outbound Referral Processing
- MCO File Ingestion & Care Gap Closure
- Automated Patient Outreach (SMS, Email, Voice AI)
- Appointment Scheduling in athenahealth
- Payer Portal Integration
- Reporting & Analytics
Integrated with athenahealthYour turn