Referral capture in the 340B world is not a new concept. What it requires is a Holmes and Watson investigative spirit, time, and most importantly…an eye focused to Compliance.
In the 340B world, we live and die by the 340B patient definition. HRSA has given very specific guidelines that qualify a 340B prescription. First, the drug must be a covered outpatient drug. Second, the covered entity must have a relationship with the patient that is clearly documented in the health record. Third, the individual must have received care from a health care professional employed or under a contract or other arrangement (referral). Fourth, that the covered entity remains responsible for their care with respect to the drug. HRSA has made it clear that an individual will not be considered a patient of a covered entity if the only health care service received by the individual from the covered entity is the dispensing of a drug or drugs for subsequent self-administration or administration in the home setting.
A referral capture is looking for a way to tie a visit with a non-qualified referred provider to a qualified provider visit. This referred provider may not work in the parent or child sites/associated sites of the entity. However, if we can ‘close the loop’ on the documentation between the referred provider and the covered entity, you may be able to claim those prescriptions as eligible. These types of relationships are especially advantageous in facilities that have primary care services and a referral documentation process.
In order to have a compliant program, which is key here, you must make sure you can support any referral claim with documentation. It may seem easy to capture a referral once and rely on the patient or referred provider to be associated with an eligible claim every time, but unfortunately it does not work this way.
A great way to dip your toes into the referral pool is to work with your third-party 340B vendor to see if they can provide you with a list of prescriptions that did not qualify based on your established eligibility criteria. You can then review the medical record for any patients with whom your entity has an established relationship to determine if the following elements are present:
- A referral out from the patient’s primary care provider.
- A note back from the specialist, including a date, the provider the patient saw, and the medication prescribed.
- This provider should match the fill from the entity’s contract pharmacy.
- The medication is on the patient medication list in the entity’s health record.
There you have it; a closed loop!
Unfortunately, this review process can be quite labor intensive. Members of the entity’s 340B team can dedicate time each week or month to research potential claims and manually qualify them, but what do you do if you are a small facility, or don’t have 340B staff resources available to research the claims appropriately? SpendMend Pharmacy is here to help! One of our newest service lines is 340B retail referral capture. Reach out to your auditor or our Leadership team to discuss this potential opportunity for your site at email@example.com. SpendMend Pharmacy has developed this program based on our HRSA audit experience, so you can feel confident that it will be compliant. It is our specialty!