by Melissa Opraseuth, PharmD
Referral prescriptions can be an important additional source of 340B funding for covered entities (CEs). However, it wasn’t until recently that referral prescriptions moved out of the “grey area” of 340B and into the mainstream. Just three years ago, most CEs avoided this area due to operational and compliance concerns. Today, many CEs have already added referral prescription capture to their 340B programs or are actively evaluating solutions.
It’s largely due to the funding opportunity, as well as the addition of new vendor solutions that inspire confidence in compliance. par8o 340B Referral Capture client average monthly savings ranges from $1,500 a month to $35,000, with some seeing over $60,000 a month in savings. These savings can be incredibly valuable in 340B’s mission to “stretch scarce federal resources as far as possible, reaching more eligible patients and providing more comprehensive services.” Moreover, all of par8o’s 340B referral prescriptions subject to audit by HRSA have passed.
For those yet to make the change, here are five key steps to capturing referral prescriptions.
- Determine the Opportunity: Consider Referral Volume & Related Specialties
A basic opportunity analysis involves evaluating three key areas: referral volume to outside or non-eligible specialists, commonly referred-to specialties, and the average value of resulting prescriptions. Some specialties result in higher-cost prescriptions than others, which can make adding referral prescriptions to your 340B program a wise financial choice.
If you have an in-house pharmacy, prescriptions written by specialists at ineligible sites may also potentially be included in a 340B program, but will need a similar documentation approach to scripts filled at a contract pharmacy.
- Research Referral Prescription Vendor Solutions
Many TPAs offer the ability to purchase access to referral solution data as an add-on to your existing contract. These solutions vary in terms of comprehensiveness and can sometimes be a simple data download. In these cases, referral follow-up and documentation are the CE’s responsibility. Some CEs have dedicated referral teams to perform these tasks. Even with a referral team, however, prescriptions from certain contract pharmacy chains may not be available to you without partnering with specific vendors.
If you don’t have a dedicated referral team, focus on partnering with a vendor that specializes in concierge-style referral capture services. Be sure to compare all costs of the program, including implementation fees and monthly data fees, which some TPAs charge in addition to a percentage of each claim captured.
3. Determine Compliance Approach & Parameters
Beyond HRSA’s guidelines, there are several parameters that can be used to determine whether a specific referral prescription can be captured for a 340B program. Some of these parameters are up to your CE’s discretion as they are not mandated by HRSA, such as the most recent encounter date both at the 340B CE and the specialty office. Both of these date ranges factor into proving “ownership of patient care.”
If you are opting to capture referral prescriptions in-house, be sure that you are fully knowledgeable in this area. The National Association of Community Health Centers, 340B Health, and some specialty vendors such as par8o put out guidelines on referral prescriptions that can help keep you up-to-date with compliance best practices; you’ll also want to check in with your counsel as well as your compliance consultant should you have one.
If you choose to utilize a vendor to capture referral prescriptions, find out what the vendor’s baseline approach is and whether you can modify it to fit your CE’s approach. You’ll also want to evaluate a vendor’s internal self-audit practice, frequency, portal usability, and post-onboarding support. What is the vendor’s approach to preventing duplicate discounts? How easy is it for you to audit an individual capture within the vendor’s portal?
4. Consider Specialty Contract Pharmacies
Analysis shows that clients with specialty contract pharmacies see a higher per-claim average savings on referral prescriptions than those without. If you do not already have specialty contract pharmacies in place, adding them to your network will greatly benefit your 340B referral prescription capture program.
5. Review and Update 340B Policies & Procedures
Your assigned auditor may refer to your Policies & Procedures (P&Ps) to determine whether a script is eligible for 340B, especially if the prescription is a referral prescription. As long as the prescription followed your stated requirements, the requirements will likely align with HRSA’s compliance requirements, and the script was not also submitted for Medicaid pricing, the prescription should meet 340B requirements.
If you don’t already have your approach documented, you’ll need to determine how specific your P&Ps should be, and make sure that your 340B team understands and follows your documented approach. An ideal vendor partner will also help you review and update your P&Ps to mirror the approach they take, especially if it’s a concierge-style service.
par8o is proud to offer its 340B Referral Capture clients complimentary P&P review and consulting. We also offer quarterly informational webinars to help the 340B community learn about referral capture requirements.
Join par8o this coming Tuesday, March 16th, at 2 p.m. EST for a complimentary webinar, “Audit-Readiness with 340B Referral Capture: Portal Preview.” You’ll see how each captured prescription includes an easy-to-follow audit trail and learn about par8o’s approach to compliance. This webinar is for covered entities and 340B provider consultants only and you can register here. We hope you can join us!
Melissa Opraseuth, PharmD, is Chief Operating Officer of par8o. For questions, please contact Jen Tagliaferro at firstname.lastname@example.org