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Optimizing 340B Savings Through Referrals

There are several ways to enhance, boost, and optimize 340B savings. In this blog, we’ll look at how capturing referrals can benefit your 340B program savings.

HRSA Guidelines Regarding Referrals

According to HRSA guidelines, a covered entity may send a patient to an outside clinic not registered with 340B and consider the patient 340B-eligible only if the patient receives healthcare from a healthcare professional who is either employed by the covered entity or provides healthcare under contractual or other arrangements (e.g., referral for consultation) such that the responsibility for the patient’s care remains with the covered entity. If the covered entity can document that it retained responsibility for the healthcare services provided to the patient, then that individual may be eligible to receive 340B drugs from the covered entity.[i]

To meet these criteria, the covered entity’s medical record must show the referral order by the eligible provider in an eligible clinic, as well as a summary of the diagnosis and care provided by the referred specialist back in the patient’s medical record.

Maximizing Savings

HRSA guidelines state that:

  1. The covered entity must remain responsible for the care of the patient
  2. There must be an order for referral in the covered entity’s owned medical record for the patient
  3. There must be a summary of the referred provider’s care maintained in the covered entity’s medical record for the patient, and this summary should include any prescriptions provided to the patient, which will allow for auditing
  4. The referred specialist does not need to be a member of the covered entity’s medical staff if all the above criteria are met

Depending on the demographics of the covered entity’s patient population, estimates are that 25% to 35% of a hospital’s contract pharmacy potential lies in referral prescriptions. The numbers trend higher on specialty drugs, which also tends to be an area with increased savings opportunities.

Suppose you could capture even half of that number. How much would a 10% to 20% or more increase in savings augment your organization’s financials? So why isn’t everyone already capturing referral prescriptions?

Manual or Third-party Referral Capture

If your organization is not able to bring on assistance to run a new program, consider having internal staff perform the referral capture process manually. This involves auditing each potential referral capture prescription on a regular basis to validate that all of the referral prescription eligibility elements are present.

The first question we often receive about performing the validation process manually is “How many hours does it take?” This will depend on the number of specialists/referring providers you have along with their average volumes, but the guarantee is that it will take significant additional resources in the form of staff and time.

For many covered entities, the manual referral capture process may not be a viable solution because of the necessary additional resources; in such cases, your decision may be to seek the assistance of an outside vendor in compliantly capturing 340B claims from referrals. This is where the 340B Solutions team from CPS can be of help.

CPS has the extra benefit of its vast knowledge of establishing and maintaining a compliant program, along with pharmacy operations experience to manage a 340B referral capture program efficiently and effectively for your covered entity. CPS can capture additional referral capture savings above and beyond what may be identified through a manual program, because CPS has the infrastructure in place to track down missing documentation in the medical record that will allow the transaction from the referral provider to qualify for 340B. In addition, we bring thousands of hours of 340B experience, both in implementing and then optimizing 340B Programs. We can assist in the process, avoiding pitfalls and helping gain added savings while maintaining compliance.

Incorporating referral capture into your 340B program will net sufficient savings to be a valuable addition to your program. For assistance in maximizing your 340B program by adding referral capture, reach out to the Comprehensive Pharmacy Services 340B Solutions team at 340BHelp@cpspharm.com .

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[i] https://www.hrsa.gov/opa/updates/august-2014.html. Accessed 3.23.21

Posted: Monday, March 29, 2021

Tags: 340B, CPS Blog Posts