Innovating PRC to Stop the Financial Leak

For many tribal health organizations, IHS facilities, and P.L. 638 programs, Purchased/Referred Care (PRC) is where the hardest tradeoffs happen. A limited budget, a medically necessary referral, and a community member waiting for care all meet in the same place. When a PRC program is running well, patients get the care they need and dollars stretch further. When it isn't, denials pile up, staff burn out, and trust erodes. Below are five areas where redesign work tends to deliver the fastest, most durable gains.

1. Start with the referral workflow, not the budget

It is tempting to treat a PRC shortfall as purely a funding problem. More often, the bottleneck is the workflow: how referrals are received, triaged, authorized, and tracked. Mapping the referral process end to end usually surfaces duplicated steps, unclear handoffs, and delays that cost both time and money. Fixing the workflow first means every dollar that follows is spent on a cleaner, more accountable process.

2. Strengthen eligibility and alternate resource verification

PRC is the payer of last resort, so consistent verification of alternate resources — Medicaid, Medicare, private insurance, and VA benefits — protects the program's limited funds. Building a reliable, documented verification step early in the referral process reduces improper payments and frees resources for the members who truly have no other coverage.

3. Make medical priority levels work for you

Medical priority determinations are among the most sensitive decisions a PRC program makes. Clear, consistently applied criteria — paired with transparent communication to patients and providers — reduce disputes and help the community understand how decisions are made. Consistency here is as much about trust as it is about compliance.

4. Close the loop on documentation and reporting

Strong documentation is what makes a PRC program defensible in an audit and fundable in the next cycle. When authorizations, denials, and deferrals are recorded consistently, leadership can see spending patterns clearly and make the case for additional resources. Good reporting is not overhead — it is how a program tells its own story with data.

5. Invest in the people running the program

PRC staff carry enormous responsibility, often with little formal training and high turnover. Cross-training, clear procedures, and ongoing professional development turn a fragile program that depends on one or two people into a resilient one. Workforce development is not separate from PRC redesign — it is what makes the redesign stick.

A community-centered approach

Behind every PRC decision is a person and a family. The goal of redesign is never just efficiency for its own sake — it is restoring balance so that limited resources reach the people who need them most. When workflow, verification, priority criteria, documentation, and staffing all work together, a PRC program becomes something communities can rely on.

If your organization is weighing a PRC redesign, we would love to help you find the first, highest-impact place to start. Reach out anytime to start the conversation.