Why Finding a 340B Referral Isn’t the Same as Capturing It

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Artificial Intelligence (AI) is reshaping 340B referral capture, and it is only ramping up from here. I have seen that firsthand working with hundreds of covered entities (CE) over the last four years. Here is what AI does well:

• Identifying referral opportunities by ingesting structured referral data from the Electronic Medical Record (EMR) and matching it to the right patients and specialists.
• Reading existing specialist notes and identifying key compliance details such as date of service and medications mentioned.

Yet something still exists between and after those two processes. The capture gap is the distance between finding a 340B-eligible referral and getting paid for it. Someone still needs to connect the right notes to the right referrals, because the bar is documentation—not detection.

HRSA’s patient definition guidance sets it: the service must fall within the CE’s approved scope, and the CE must demonstrate responsibility for the patient’s care. With the definition under active litigation, it is increasingly important that CEs are deliberate about the documentation required to demonstrate care ownership: outlining it in their 340B policies and procedures, and ensuring referral claims are captured accordingly.

The compliant 340B referral loop typically involves four elements:

1. CE’s scope of care for the patient
2. Referral arrangement or acknowledgement of specialty care
3. Evidence of care coordination: specialist notes, a care summary, or documented attempts to retrieve them
4. Prescriptions from specialists correctly attributed to the CE’s 340B program

#2 and #3 are where the biggest gaps are.

An AI model that only retrieves what is already in the CE’s EMR cannot build a case for care ownership when no structured referral exists, a common scenario when a patient self-refers or specialist care was already established. Nor can it produce specialist notes that live only in the specialist’s chart and were never sent back.

A Health Affairs Scholar census of the 340B TPA market identified 48 firms. Only nine offered referral management. I believe that decision comes down to solving #2 and #3.

How to close the Capture Gap

Specialist engagement. AI can queue the request ifa reliable provider directory exists. No centralized database consistently carries up-to-date provider specialty and contact information, so it has to be built. I also rarely see AI optimizing release and follow-up in ways that do not inundate provider offices. This is the most challenging piece of referral capture, which is why many solutions stop before specialist record retrieval and hand the CE a review queue instead. That’s inadequate when the CE is already short-staffed, and it leaves compliant 340B savings on the table.

A collaborative relationship. What AI cannot replicate is human relationships, and 340B is rooted in community: CEs, technology partners, consultants and other experts. One of my favorite questions to ask about 340B qualification is “Why did the claim fail?” Partners who take a broad view of care ownership help CEs find more than one path to compliant capture. When no structured referral exists, other documentation in the EMR can still establish the relationship: acknowledgement of specialty care in the CE’s patient care notes, an exchange of care plans between the CE’s primary care provider and the specialist, or a complete patient care team in the record. The point is not simply to find a referral record but to document the broader care relationship.

Enhanced claim matching. A key point of leakage happens before referral data is even identified. It is when a claim fails to be recognized as the CE’s patient because of a different name spelling, or a timing gap in prescription order dates between the pharmacy and the EMR. Or when a patient is wrongly deemed inactive because a clinic location was omitted from the EMR feed. This is where multiple, distinct rules built for different failure modes close the capture gap.

Capture has to reach the pharmacy the patient chose. A CE’s patients may be filling across national retail chains, independent pharmacies and specialty pharmacy networks. AI can only work with the data sources available to it, so AI alone does not guarantee that all referrals get captured. Finding the referral opportunity is only valuable if the solution connects it to the prescription and the pharmacy where the patient actually fills it, so CEs must evaluate what pharmacy coverage a referral solution includes.

What do I do next?

Ask the right compliance questions during audits. Set an audit standard across your 340B partners and adhere to it, whether that means reviewing a percentage of captured claims or a defined number. Scrutinize it before an external auditor does. An FQHC in Indianapolis left our referral capture program for a lower-cost alternative and later returned. Their internal audit found the referral claims missing documentation traced to the other program, leading to reversals that hit inventory management and cash flow for both the CE and the contracted pharmacies. Capture volume alone is not the measure of a successful referral program. The claims need to withstand scrutiny.

Keep patient outcomes at the forefront. An unexpected source of fuel I have found to have tremendous impact is the patient story. A rural Arizona health center used 340B savings to fund an OB/GYN clinic in a community with no off-hours obstetric care. Grants and visit revenue alone could not cover the operating cost; 340B dollars could. They did exactly what the program was intended for: expanding access for the patients who need it most. That access contributed to meaningful improvements in maternal-fetal outcomes, a result no 340B vendor dashboard reports. Stories like this are also critical to advocacy, at a time when the integrity and sustainability of 340B matter more than ever.

AI will continue to get better at finding opportunities. But finding an opportunity is not the same as capturing it.

Closing the Capture Gap means connecting detection to documentation, care ownership, specialist engagement, claim matching, and the pharmacy the patient chose. That is where the real value of 340B referral capture is.

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