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Find the Care Your Primary Care Panel Planned but Never Received
Find patients who may qualify for APCM, CCM or PCM, preventive care past due, orders never completed, and specialty referrals that leave your network, all ranked for your team.
What is primary care revenue intelligence?
Primary care revenue intelligence finds care a primary care group planned but did not deliver: patients who may be candidates for APCM, CCM or PCM, preventive and chronic visits past due, open orders and missed visits, and specialty referrals that leave your network. Nuvory is healthcare revenue leakage intelligence; it ranks each opportunity and routes care management candidates to clinician review.
Where does a primary care panel leak revenue?
Primary care leakage is spread thin across many patients. No single gap is large, but together they shape a group's revenue and its quality scores.
Care management candidates
Patients who may qualify for APCM, CCM or PCM and are not enrolled, routed to clinician review.
Learn morePreventive and chronic recalls
Annual wellness visits, chronic condition visits and preventive care your clinicians track, past due.
Learn moreOpen orders
Mammograms, colorectal screening referrals, labs and imaging ordered and never completed.
Learn moreNo-shows not rebooked
Missed visits with no new date after 7 days, configurable.
Learn moreOutbound referral leakage
Specialty referrals that go outside your network, in a leadership view on Enterprise.
Learn moreOne ranked list per patient
All open items for a patient, ranked so the MA or care manager raises the right one.
Learn moreSee your care management and recall opportunities
Book a primary care demo and we will show how Nuvory finds candidates and overdue care across a group like yours.
Why does planned primary care go undelivered?
Planned care goes undelivered because the panel is large and the visit is short. A clinician has minutes to address the reason for the visit, and preventive care, open orders and care management enrollment compete for the same time. Anything not raised at the visit waits for the next one, which may not be booked.
Care management programs need someone to find candidates. CCM, PCM and the APCM codes introduced for advanced primary care each have their own requirements, and identifying candidates chart by chart takes clinical time few groups have. Finding APCM candidates is a good example: the work is less about any one patient and more about seeing the whole panel.
Outbound referrals are the other big gap. When a primary care clinician refers to a specialist, the patient may go to any group they choose or the first one with an opening. For health systems and groups with their own specialists, that outflow matters, but it is hard to see without linking referrals to where care happened. Network Intelligence shows where referred patients received care, on Enterprise.
- Short visits, long lists Preventive care and open orders compete with the reason for the visit.
- Program requirements Each care management program has its own criteria, and clinicians decide who fits.
- Panel size Overdue patients are spread across thousands of charts.
- Referral destinations Specialty referrals go wherever the patient chooses, often outside the network.
How does primary care revenue intelligence work across a whole panel?
Nuvory reads diagnoses, visits, orders, recalls, referrals and program enrollment from your EHR every night and links them per patient. It finds patients who may be candidates for care programs and are not enrolled, preventive and chronic visits past due, orders not completed and missed visits not rebooked. It is primary care revenue intelligence built to produce a list someone works, not a dashboard someone reads.
- Diagnoses and visits Chronic conditions, last visit and next visit.
- Program enrollment Current APCM, CCM, PCM, RPM and BHI enrollment, so enrolled patients are not flagged again.
- Recalls and orders Preventive recall dates your clinicians track and open orders with status.
- Referrals Outbound specialty referrals and, on Enterprise, where care actually happened.
- Claims and HIE (optional) Where connected, they show care received elsewhere and make completion matching more precise.
Who decides who qualifies for a care program?
Your clinicians. Nuvory identifies patients who may be candidates based on available data. A clinician reviews each one, clinical validation may be required, and nothing is enrolled without clinician approval and patient consent.
Who on a primary care team acts on the list?
Primary care teams already do outreach. Nuvory decides who comes first and closes the loop.
- Clinical reviewerA physician or nurse lead signs off each rule from HealthArc templates after spot-checking real patients.
- Care managerReviews care management candidates with clinicians and enrolls patients who consent, with your team or the HealthArc care team.
- MAs and front deskSee open items for patients already on the schedule, so overdue preventive care is raised at the visit.
- Outreach staffWork overdue recalls and missed visits, ranked by estimated value, urgency and confidence, and call from Nuvory with verified practice numbers or hand the list to a connected texting vendor.
- Referral coordinatorFollows up on outbound referrals your team tracks; on Enterprise, leaders see where they went.
- Medical director and COOReview program growth, recall completion and, on Enterprise, network outflow by destination.
Grow care management with clinician review built in
See how Nuvory surfaces APCM, CCM and PCM candidates and overdue preventive care for your team.
Which primary care metrics link outreach to completed care?
Pick metrics that link outreach to completed care across the panel. Completed care after detection is compared with your baseline as correlation, never as proof that outreach caused it.
| Metric | What it shows |
|---|---|
| Care management candidates reviewed | Candidates surfaced, reviewed by clinicians and enrolled with consent. |
| Preventive recall completion | Overdue preventive visits and screenings completed after outreach. |
| Open order closure | Ordered screenings and labs completed or closed with a reason. |
| No-shows rebooked | Missed visits with a new date. |
| Outbound referral leakage | On Enterprise, specialty referrals completed in versus outside your network, by destination. |
How does Nuvory fit primary care EHRs and care management platforms?
Nuvory works alongside your EHR, reminder tools and care management platform. It does not replace them. Nuvory is designed to work with data from athenahealth, where the connection is live, and from eClinicalWorks, Practice Fusion and other supported EHRs through FHIR R4 APIs and, where the EHR supports it and your organization enables it, bulk export and SMART on FHIR. Scope and data availability are confirmed during discovery.
Network Intelligence, the outbound leakage view, is a leadership tool on the Enterprise plan. It shows where patients go, not a call list. Read more in where patients go, and see security for the BAA and access controls.
What should a primary care group require from a tool?
Ask whether a tool finds care management candidates without enrolling anyone automatically, skips enrolled and booked patients, surfaces open items at upcoming visits, and shows where outbound referrals go.
Further reading
CCM, PCM, APCM and RPM eligibility explained: finding candidates without adding staff
How CMS describes CCM, PCM, APCM, RPM and related programs, which signals make a patient a candidate for clinician review, and how to run that review queue.
Referral IntelligenceWhat is patient leakage? How to measure network leakage and outmigration
How multi-site groups and MSOs measure patient leakage: outflow formulas, what each data source shows, and how to separate avoidable from payer-directed care.
Patient RecallPatient Recall Management: A Guide for Specialty Practices
How specialty practices find overdue recalls, rank them, reach patients and confirm the care was done.
Questions, answered
More in our FAQ, or ask our team.
How does Nuvory help find APCM candidates?
Nuvory looks across your panel for patients who may be candidates for APCM based on available data, and routes them to clinician review. Clinicians decide who fits, and nothing is enrolled without clinician approval and patient consent. Billing rules are applied by your team.
Can Nuvory find CCM and PCM candidates?
Yes. Nuvory flags patients who may be candidates for CCM or PCM and are not enrolled. Every candidate goes to clinician review. Clinical validation may be required.
Does Nuvory handle preventive recalls?
Yes. Recall Intelligence finds patients past preventive and chronic recall dates your clinicians track, skips patients already booked, and closes the item when care is completed.
What is Network Intelligence for primary care?
It is a leadership view of outbound referral leakage: where referred patients actually received care. It is available on the Enterprise plan and is not a call list.
Does Nuvory enroll patients in care programs?
No. Nuvory identifies candidates. Your team or HealthArc's care team enrolls patients after clinician approval and patient consent.
What does Nuvory cost for primary care?
Starter is $149 per provider per month for Recall Intelligence. Growth is $299 and adds Care Management, Referral, Scheduling and Opportunity Intelligence. Enterprise adds Network Intelligence. See pricing.
See Nuvory with a primary care workflow
Book a primary care demo to see care management candidates, overdue recalls and outbound referrals for your group.