Sometimes, reliance on a referral request to an outside prescriber (e.g., specialist) to qualify a prescription as 340B eligible can be relatively straightforward. For instance, when a direct referral request to the actual prescriber is documented in the patient’s medical record along with a referral visit summary back closing the loop, the covered entity’s responsibility of care can be clearly demonstrated.
However, sometimes reliance on a referral request may not be so straightforward. Consider, for instance, an indirect referral that is not to the actual provider that ends up writing the prescription. For example, the referral might be to a provider, but another provider in the same practice group ends up writing the prescription, or the referral might not name a specific provider and instead name a practice group in general. As another example, the referral might be to a provider who, in turn, refers the patient to another outside provider or practice group. When relying on these types of indirect referrals, there are steps that can be taken to mitigate the risk due to the covered entity’s responsibility of care being called into question:
Include language in 340B policies-procedures of how the patient’s coordination of care is managed by the covered entity, thus demonstrating that responsibility for the patient’s care remains with the covered entity. How does the covered entity maintain responsibility of care in these situations?
Ideally, if possible, try and establish some sort of standing referral agreement (if possible) between the covered entity and the practice group. This is especially important when the referral is to a practice group in general rather than to a particular provider.
Maintain full documentation in the patient’s medical record of the referral request, the second referral request to a second provider/practice group (if applicable), the referral summary back from the prescriber describing the care provided, and ideally a review of the referral summary by the covered entity’s provider demonstrating that the covered entity maintained responsibility for the patient’s care during the process.