Healthcare organizations are chasing direct-to-employer contracts. The pitch is compelling: transparent pricing, no authorization headaches, high-value surgical cases. But for most orthopedic practices, the direct employer relationship remains aspirational.

Aggregators offer a more practical on-ramp.

Companies like Transcarent, Carrum Health, and Coral have already done the work of contracting with employers. They bring together employer populations under bundled payment arrangements and steer those patients to quality providers. For independent orthopedic groups, aggregators represent an accessible entry point into value-based care without the complexity of negotiating directly with every self-insured employer in your market.

The opportunity is real. The navigation platform market is valued at $10.1B and expected to reach $24.8B by 2034. These platforms steer millions of patients annually. Accolade alone manages over 14 million member encounters per year.

But winning these referrals and keeping them requires infrastructure most practices don't have.

Proliance Surgeons, a 25-care-center orthopedic organization in Washington State, figured this out the hard way. They built a system from scratch, scaled it across eight aggregator partners, and eventually 3x'd their volume from one partner alone.

In a recent webinar, Tina Girardi (Director of Value-Based Care & Clinical Network Development) and Natalia Hairston (VBC Referral Coordinator) walked through exactly how they did it.

Here's what they learned.

Why Aggregators Exist and What They Expect

Before diving into workflows, it helps to understand what you're working with.

Aggregators contract with self-insured employers to provide musculoskeletal care at transparent, bundled prices. The employer pays a single fee that covers the consultation, surgery, facility, anesthesia, and follow-up care. No surprise bills. No authorization delays.

For the patient, it's a white-glove experience. A dedicated navigator at the aggregator coordinates everything. They handle scheduling, answer questions, and ensure the patient gets to the right specialist at the right time.

For the provider, these referrals come with strings attached.

Aggregators require fast response times, often within 24 to 48 hours. They need clear communication about case status. They track everything and report back to their employer clients on metrics like time-to-appointment, surgical conversion rates, and patient satisfaction.

Providers who can't meet these expectations get dropped from the network.

The good news: each aggregator sends relatively few referrals. The challenge is that each one has different submission methods, different portals, different contacts, and different service level requirements.

Managing one aggregator is straightforward. Managing eight across 25 care centers without centralized scheduling requires a system.

What Proliance Built Before Any Technology

When Tina joined Proliance, the organization was already working with a few aggregators. But referrals were scattered across inboxes, care centers were unclear on expectations, and there was no visibility into what was happening with these high-value patients.

Her first step was getting in the weeds.

She set up calls with navigators at each aggregator to understand their processes. If they used a portal, she learned the portal. She mapped out what information came with each referral, what service levels were required, and who the key contacts were.

Then she started building.

The foundation was an Excel spreadsheet. Not glamorous, but it solved the immediate problem: centralizing all referrals in one place so nothing fell through the cracks.

The spreadsheet tracked essential fields: patient name, which aggregator sent the referral, the patient's condition, the navigator contact, communication dates, and a status column that served as a running log of every touchpoint.

That status column became critical. Every email sent, every follow-up, every update from the care center went into that log with timestamps. It created an audit trail and made it possible to pick up any case instantly without digging through email threads.

But centralizing referrals was only half the problem.

The Care Center Education Problem

Proliance has 25 care centers, 15 ambulatory surgery centers, and no centralized scheduling. Each center operates somewhat independently. When Tina started sending aggregator referrals to care centers, the response was underwhelming.

Referrals would sit. Care centers didn't understand the urgency. Some didn't know what a bundle was or why these patients needed different handling than standard referrals.

The fix was education.

Tina went to service line meetings and explained the fundamentals: what value-based care is, what transparent pricing means, why employers are moving in this direction, and critically, what the service level commitments were.

She also standardized the communication. Each referral email to a care center followed a template that included the aggregator name, patient details, the response deadline, and exactly what action was needed. No ambiguity.

When care centers didn't respond, she followed up. Not aggressively, but consistently. She documented everything in the spreadsheet status column, which created accountability and surfaced patterns over time.

Some physicians wanted to review records before scheduling. Others would take any case immediately. Tina learned each center's preferences and built that into the workflow.

The System That Enabled 3x Growth

Four months in, Tina hired Natalia to help manage the growing volume. The spreadsheet had expanded. The notes column was getting longer and longer as they documented each referral's journey.

Natalia describes her initial training as overwhelming. There was so much nuance to each case, so many different aggregators with different requirements, so many care centers with different preferences.

But the system held.

The key principles that made it work:

1. ‍Centralize everything.
    Don't scatter referrals across multiple sheets, inboxes, or systems. You need one place to check, not eight. When Natalia opens the spreadsheet, she can see every active referral across every partner. She filters by partner when she needs to focus on one aggregator's cases, but the complete picture is always visible.
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2. Understand all perspectives.
    Every referral involves multiple stakeholders with different priorities. The patient needs fast, convenient care. The employer (through the aggregator) needs documented outcomes and SLA compliance. The aggregator navigator needs clear communication. The care center needs enough information to act. Your system has to serve all of them.
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3. Embrace low volume, high yield.
    Don't be intimidated by working with multiple partners. Each sends relatively few referrals, but each one represents significant value. A single aggregator might send one to five referrals per month to a given care center. That's manageable volume, but only if you're organized.
   ‍‍

4. Standardize your messaging.
    Template your emails. Include the aggregator name, patient details, response deadline, and exactly what action is needed. This reduces errors and makes it possible for anyone to pick up a case if needed.
   ‍‍

5. Enforce service level expectations.
    These referrals have strict timelines. If you don't hear back from a care center, follow up. Document everything. The aggregator is tracking whether you meet your commitments, and they will move volume to providers who do.

The spreadsheet became the source of truth. But as volume grew and more aggregators came online, the manual work was becoming unsustainable.

Scaling Beyond Spreadsheets

Proliance eventually moved their VBC referral workflow onto the Hatch platform. The results speak for themselves: 77% reduction in time to triage, 2-day reduction in time to completed referrals, and the ability to finally report on conversion rates and partner performance with confidence.

But the technology only worked because the system was already sound.

Natalia describes the transition as Hatch automating what they had already built. The platform's AI referral import feature pulls information from aggregator emails directly into the system. Location-based routing helps identify the best care center for each patient based on proximity. Standardized instructions ensure every referral goes out with the right context.

The fundamentals didn't change. What changed was capacity. Natalia can now handle more volume with greater precision, and Proliance has visibility into which partners and care centers are performing.

A Checklist for Getting Started

If your organization is considering aggregator partnerships or trying to systematize the ones you already have, here's where to start:

Foundation

• Identify all current aggregator relationships and their requirements

• Document the submission method, portal access, and key contacts for each

• Establish your standard service level commitment (most aggregators expect 24-48 hour response)

• Identify a single person or team responsible for managing these referrals centrally

Workflow

• Create a single tracking system for all VBC referrals (start with a spreadsheet if needed)

• Define required fields: patient info, aggregator/partner, navigator contact, condition, status log

• Build email templates for sending referrals to care centers

• Establish follow-up cadence when care centers don't respond

Education

• Brief care center staff on what value-based referrals are and why they matter

• Clarify the specific SLA requirements for each partner

• Create documentation that care centers can reference for each aggregator relationship

Reporting

• Track referral volume by partner

• Track conversion to surgery

• Monitor response times to identify bottlenecks

• Review performance with care centers regularly

Resources

Tina and Natalia have made their VBC referral tracking spreadsheet available as a template. It includes the core structure they used to manage eight aggregator partnerships, along with guidance on how to use it and the principles that made their system successful.

Download the VBC Referral Tracking Template →