Establishing a referral prescription capture program enables covered entities to broaden the reach of their 340B Drug Discount Program. Referral prescription capture can occur when patients of the covered entity utilize external specialists who are outside of the health system’s physician network. Monitoring these opportunities not only increases the prescription volume that qualifies as 340B eligible, but the associated financial savings can help covered entities to achieve the 340B mission to “stretch scarce federal resources as far as possible, reaching more eligible patients and providing more comprehensive services.”
HRSA Guidelines Regarding Outpatient Prescription Referrals
According to HRSA guidelines, a covered entity may refer a patient to a non-qualified 340B facility while maintaining responsibility for the patient’s care. This can occur if the patient receives care from a healthcare professional who is either employed by the covered entity or provides care under contractual or other arrangements (e.g., referral for consultation) such that the responsibility for the patient’s care remains with the covered entity. To meet these criteria, best practice dictates that the covered entity’s electronic health record (EHR) includes the eligible provider’s referral order from an eligible location and a summary of the diagnosis and care provided by the referred specialist sent back to the covered entity’s EHR.
Depending on the demographics of the covered entity’s patient population and their provider network, estimates indicate that 25% to 35% of a covered entity’s contract pharmacy potential lies in referral prescriptions.
The numbers trend on the higher end of this range with specialty medications, which offer increased 340B savings opportunities. Best practice guidelines regarding referrals include the following:
- The covered entity must remain responsible for the care of the patient in order to meet HRSA’s definition of a 340B eligible patient
- The covered entity’s EHR should contain a referral for the patient
- The covered entity’s EHR should contain a summary of the referred provider’s care along with documentation of any ordered prescriptions
- The referred provider does not need to be a 340B eligible provider of the covered entity if all the above criteria are met.
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