Mitigating Risks of Indirect Referrals

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Mitigating Risks of Indirect Referrals

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:

Policy-Procedure Language:

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?

Referral Agreement:

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.

Full Documentation:

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.

About Author

Rich Bucher, JD, RPh, 340B ACE

Pharmacist with experience in pharmacy leadership, compliance, and contracting for a large healthcare organization and for a large regional health plan. This includes practical experience dealing with operational, compliance, and legal issues associated with managing a system-wide 340B Program. Also, over 10 years of legal practice experience, including in health care law and contracting. Rich has presented on 340B and other health care compliance topics at numerous conferences. Rich has conducted many external 340B audits and provided consultation for various covered entity types, including providing onsite support during HRSA audits. Rich is a lead auditor on our 340B independent auditing team, oversees legal and compliance issues, and provides client contract and policy/procedure reviews.

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