Although its benefits are great, the 340B Drug Pricing Program leaves a lot up to interpretation by participating health centers when it comes to compliance — especially with "referral prescriptions." Referral prescriptions — or prescriptions resulting from referrals to outside specialists — have long been a point of confusion under the 340B program. Can 340B participating organizations capture these prescriptions? If so, how?
According to HRSA 340B FAQ 1493:
If the covered entity can document that it retained responsibility for the health care services provided to the referred individual, then that individual may be eligible to receive 340B drugs from the covered entity. How a covered entity counts referrals under the 340B Program should be addressed in their written policies and procedures.
It sounds simple: A clinic may only capture referral prescriptions for its own patients. But how does a health center prove that it owns patient care?
Documenting Patient Eligibility & Continuity of Care
340B participants must show that they are the central entity responsible for a patient’s care, even when a patient sees a specialist at a different facility.
This could include documenting referrals, providing proof of provider-entity relationships and maintaining patient notes from internal and external providers. At minimum, HRSA requires the referral documented in the EHR, and proof of patient encounters with both the referring and referred-to providers.
But "audit-proof" 340B referral prescription claims go much further. Our client's Policies & Procedure account for a variety of qualification scenarios. For example, how long after a patient’s visit (as documented by the encounter in your EHR) is the patient still considered active? Must a patient have visited your primary care facility in the last 6 months? 12? 24? How will you handle refills prescribed by specialists? These types of parameters should inform whether your facility truly owns (or still owns) a patient's care, and whether a related referral prescription is considered valid.
Managing these requirements can place a significant work burden on a pharmacy manager-turned 340B Program manager, which is the case for many health centers. Many health centers instead choose to forego 340B savings from referrals — but that revenue could add to an already vital source of income for resource-strapped federally-funded health centers.
Leaning on third-party solutions such as par8o 340B Referral Capture can fill in the gaps, support compliance and help CEs maximize their 340B savings. Watch our webinar to learn more, or schedule a meeting with us today to see how we might help your organization.