Enable CMS TEAM Success with ReferWell
From TEAM Compliance to TEAM Excellence ReferWell ensures your surgical episodes succeed by combining intelligent routing technology with hands-on care navigation to convert referrals and prevent readmissions.
The TEAM Reality
30 Days to Make or Break
Medicare Patient Post-Op Recovery
The policy requires selected acute care hospitals to coordinate care from surgery through 30 days post-hospitalization for people with, as CMS designates, Original Medicare. Hospitals paid under the Inpatient Prospective Payment System (IPPS) and located in the selected Core-Based Statistical Areas (CBSAs) are required to participate in TEAM to support the value-based care performance model.
Financial Stakes
Up to two-thirds of participating hospitals will lose revenue under TEAM according to Brandeis University analysis.
- 714 hospitals are mandated to participate
- 2% discount factor built into target prices
- One readmission can push an episode over target
30-Day Accountability
All costs for 30 days post-discharge are included in episode pricing, including readmissions.
- Average readmission cost: $15,200
- Readmission rates: 10-20% for surgical conditions
- Quality scores affect reconciliation
5 Surgical Episodes
TEAM covers five high-volume surgical procedures requiring coordination.
- Lower extremity joint replacement
- Surgical hip/femur fracture treatment
- Spinal fusion
- Coronary artery bypass graft
- Major bowel procedures
The Challenge
Hospitals need patients to:
(1) Convert referrals → see high-quality, in-network specialists for post-surgical care, and
(2) Not get readmitted → remain healthy and complete their recovery journey without complications.
Background
Beginning on January 1, 2026, The Centers for Medicare & Medicaid Services (CMS) Transforming Episode Accountability Model (TEAM) policy will reshape how care is delivered and coordinated to support Medicare patients throughout their surgical journey. About 714 acute care hospitals must comply and coordinate care from surgery through 30 days post-hospitalization for Medicare patients undergoing one of five surgical procedures:
- Lower extremity joint replacement
- Surgical hip femur fracture treatment
- Spinal fusion
- Coronary artery bypass graft
- Major bowel procedures
Solution
ReferWell is the technology partner of choice for hospitals and health systems looking to transform the trajectory of post-operative care fragmentation. To ensure your Medicare patients’ surgical episodes achieve positive outcomes, ReferWell’s intelligent software-as-a-service scheduling platform with empathetic human-led care navigation can convert referrals and prevent readmissions.
Learn how ReferWell’s Readmission Prevention Bundle Can:
- Pre-Discharge: Schedule follow-up before patient leaves hospital
- Day 2-3 Post-Discharge: Care Navigator calls patient at home
- Day 7: Ensure first follow-up happened; reschedule if missed
- Days 10-30: Monitor for warning signs, coordinate specialty care
- Continuous: Real-time alerts if patient visits ER
The expected impact achieves:
Industry baseline: ~15% readmission rate
With comprehensive care navigation: 10-12%
The ReferWell Solution
Dual-Engine Solution:
Technology + Human Touch
ReferWell combines intelligent SaaS scheduling technology with highly trained care navigators to ensure every post-surgical patient gets to the right specialist AND stays out of the hospital during the critical 30-day window.
Real-time Scheduling & Intelligent Provider Matching
ReferWell’s platform uses a curated provider database and intelligent provider match search and scheduling technology that filters referral providers by insurance, subspecialty, response time, location, and language.
For TEAM Compliance, This Means:
Route to high-performers
Direct patients to specialists with lowest readmission rates
Keep in-network
57% reduction in patient leakage, keeping costs predictable
Track continuously
Real-time visibility into who showed up, who didn’t, and who needs intervention
Care Navigation Team & Empathetic Member
ReferWell’s care navigators are trained to cultivate trust and empathy with each patient. Leveraging our intelligent scheduling platform, our care navigators engage patients and schedule appointments turning outreach into completed care.
For TEAM, This Means:
Appointment shepherding
Don’t just schedule—ensure patients actually attend post-operative appointments
Barrier removal
Address transportation, mobility, work conflicts, insurance confusion
Proactive outreach
Contact patients who miss appointments before they deteriorate
Red flag monitoring
Identify warning signs of complications and intervene early
Measurable Impact
Two Critical TEAM Metrics ReferWell Drives
METRIC 1
Convert Referrals to Appointments
Target Achievement Rate
80-85%
vs. 50% industry baseline
METRIC 2
Decrease 30-Day Readmissions
Target Readmission Rate
<12%
vs. 15%+ industry baseline
Why This Matters for TEAM Compliance
Only half of Medicare beneficiaries who were readmitted within 30 days had a follow-up visit with a clinician. Roughly two-thirds of post-discharge adverse events were preventable or could have been mitigated.
ReferWell’s Results:
- Increase patient follow-through by 60-100% across all beneficiaries
- Providers close the loop 85% of the time, more than double the national average
- 30-35% more patients get post-surgical care to avoid complications
The Math:
Industry standard: 50% of referrals result in visits
With ReferWell: 80-85% visit completion rate, providing real-time insights to providers
Why This Matters for TEAM
Outpatient follow-up visits reduced 30-day all-cause readmissions by 21% in meta-analysis. Care transition programs with nurse coaches reduced readmission rates from 11.9% to 8.3%, saving $500 per case.
ReferWell’s Readmission Prevention Bundle:
- Pre-Discharge: Schedule follow-up before patient leaves hospital
- Day 2-3 Post-Discharge: care navigator calls patient at home to ensure post-op appointments are scheduled and that the patient does not have any barriers to attending their appointment
- Day 7: Ensure first follow-up happened; care navigator reaches out to reschedule if missed
- Days 10-30: Monitor for warning signs, coordinate specialty care
- Continuous: Real-time alerts if patient visits ER
Expected Impact:
Industry baseline: ~15% readmission rate
With comprehensive care navigation: 10-12%
ROI Analysis
Financial Impact
Prevent episodes from exceeding target prices through better coordination and avoid TEAM repayment amounts.
Financial Impact Per Episode
Average surgical episode cost: $30,000-50,000
One prevented readmission: $15,000 saved
One prevented complication: $8,000-25,000 saved
Network retention vs. leakage: $5,000-15,000 margin protection
Annual Impact (1,000 Episodes/Yr)
30 fewer readmissions: $450,000
Better specialist routing: $2-5M
Network retention: $5-15M
Total Potential Impact: $7.5-20M+
Critical Distinction
Why Technology Alone Fails
EMR-based referral systems can send referrals but don’t track whether patients actually showed up or help providers choose the right specialist based on quality outcomes.
What Software Can't Do
- Call a patient who didn’t schedule their follow-up
- Help a patient find transportation so they can attend physical therapy
- Recognize that a Spanish-speaking patient needs a Spanish-speaking cardiologist
- Intervene when a patient mentions symptoms of infection during a check-in call
- Navigate insurance authorization barriers in real-time
What Care Navigators + Technology Can Do
69%
ReferWell tripled patient access to specialists, achieving 69% patient follow-through with referral appointments through their combination of advanced scheduling platform and highly trained care navigators.
“The combination of technology and human touch is what makes the difference between scheduling an appointment and ensuring a patient actually receives the care they need.”
“We Keep Patients on Track”
ReferWell ensures your hospital’s TEAM episodes succeed by combining intelligent routing technology with hands-on care navigation to guarantee two things:
1. Right Specialists
Patients get high-quality, in-network, low-readmission providers
2. No Bounce-Backs
Patients don’t return to the hospital through proactive monitoring
This isn’t about managing referrals. It’s about managing the entire 30-day care journey to improve clinical outcomes and keep episode costs below target and quality scores high.
Get Started Today
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