25% – 35%
of a hospital’s contract pharmacy opportunity lies in referral prescriptions
There are several ways to enhance, boost, and optimize 340B savings. This white paper looks at how capturing referrals can benefit a covered entity’s 340B program savings and mission.
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 that patient receives care 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 services provided to the patient, then that individual may be eligible to receive 340B drugs from the covered entity.1
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.
HRSA guidelines regarding referrals state:
- The covered entity must remain responsible for the care of the patient
- There must be an order for referral in the covered entity’s owned medical
record for the patient
- 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
- 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 opportunity.
MANUAL OR THIRD-PARTY REFERRAL CAPTURE
If an organization is not able to leverage a third party to run a new program, consider identifying an internal staff member to perform the referral capture process manually. This involves auditing each potential referral capture prescription on a regular basis to validate that each of the referral prescription eligibility elements are present.
The time it takes to manually perform the validation process depends on the number of specialists/ referring providers and their average volumes. Typically, the manual process requires significant staff and time resources.
For many covered entities, the manual referral capture process may not be a solution because of the required additional resources. The second option is to seek the assistance of an outside vendor in compliantly capturing 340B claims from referrals.
CPS 340B SOLUTIONS
CPS brings decades of expertise in establishing, implementing, optimizing, and maintaining a compliant 340B program, as well as pharmacy operations experience to manage a 340B referral capture program efficiently and effectively for covered entities. 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. Thus, CPS can secure additional referral capture savings above and beyond what can be identified through a manual program.
CPS 340B teams can assist in the process, avoiding pitfalls and helping gain added savings while maintaining compliance. Incorporating referral capture into a 340B program will net sufficient savings to be a valuable addition to the program.
COMPREHENSIVE PHARMACY SERVICES
Founded 50 years ago, we are one of the nation’s largest providers of pharmacy services—employing 2,500 pharmacy professionals and serving over 800 hospitals and healthcare facilities nationwide. We help clients tackle complex problems through our suite of services across inpatient pharmacy management and consulting, 340B, specialty and ambulatory pharmacy, telepharmacy, supply chain management, rehabilitation services, and more. CPS helps pharmacy leaders achieve operational excellence, drive clinical quality, attain continuous regulatory compliance, and improve bottom-line performance while supporting pharmacy staff, caregivers, and patients.
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.
1https://www.hrsa.gov/opa/updates/august-2014.html. Accessed 3.23.21
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