What is a referral prescription or claim?

Often, primary care providers will refer a patient to another provider for a second opinion or treatment diagnosis or condition that requires advanced or specialized care. Most patient referrals are to specialty providers such as endocrinology, infectious diseases, rheumatology, dermatology, etc. – and which are not directly employed by the 340B covered entity but the covered entity has established an arrangement with. These patients continue to remain under the care of their primary care provider at the covered entity. The referring provider usually makes the arrangements for their patient to be seen by the specialty provider (e.g., make the appointment) but the specialty provider may or may not always provide any notes back to the referring provider. It is best practice for these referral specialty providers to send a note or letter back to the patient’s primary care provider, summarizing their diagnosis and treatment plan and any medications they have prescribed. Any prescription medication prescribed by the specialty provider is called a referral claim.

Why can a Covered Entity capture referral prescriptions?

Patients served by a 340B covered entity where their health records are maintained and where the referral originated and the 340B covered entity maintains the responsibility for the patient’s care can be considered for 340B drug savings. The covered entity’s providers must document the patient referral in their electronic medical records (EMR) and their 340B policies and procedures must include the process where these referral prescriptions are eligible and can be captured. The 340B covered entity is obligated to show that they are responsible for the patient’s ongoing care. Each 340B covered entity should consider having official policies around provider documentation around patient referrals.

Why should a Covered Entity consider capturing referral prescriptions?

Given the current 340B environment, it is critical for 340B covered entities to identify every potential 340B prescription to render savings back to their organization. Many smaller covered entity types are foregoing savings from referral providers because they may not be aware of how to capture these claims, have the proper 340B policies & procedures in place, they do not have a way to operationalize, or they do not have the resources to execute the process. The organizations that would be ideal to implement a referral process would be Federally Qualified Health Centers and rural, safety-net hospitals. Whether building an in-house process, partnering with your TPA or engaging a consultant, it is critical for each covered entity to compliantly capture prescriptions that render savings to help them to expand services for their communities they serve.

What does the Covered Entity need to do to be able to capture referral claims?

The covered entity needs to demonstrate that they maintain the care of the patient even when the patient is referred out of the covered entity’s four walls. The covered entity’s electronic medical record (EMR) system contains much of the needed data to document care. Common elements that support responsibility of care in a referral situation are:

• Eligible encounter at the 340B covered entity
  • Patient seen by a qualified provider at an eligible location of the 340B covered entity
• Documentation of the outgoing referral
  • Copy of referral form including reason for the referral to an outside provider
• Referral summary maintained by the covered entity
  • When a patient has a referral visit to an outside provider, the referral visit summary should be sent back to the 340B covered entity and logged in the patient’s medical record
• Policies and procedures to identify 340B eligibility
  • Definition of a referral prescription
  • Process for identifying and capturing referral claims either manually or through an automated service

What is the process to capture referral claims?

The process of identifying and capturing referral claims can be tedious. Each 340B covered entity might use a unique process in terms of how they operationalize referral relationships, documentation and validate claims. Some 340B covered entities have a very manual process that utilizes their staff to review the claims per their policies and procedures and compare documentation in the EMR. Other covered entities rely on the settings that they have put in force in their 340B Third-Party Administrator logic and others employ a consultant or additional software platform to process referral claims. Ideally, the process to identify the referral claims and validate for 340B patient eligibility should be easy to review, reject, or approve with documentation for these claims within the 340B covered entity’s capture system. Just like other 340B eligible claims, referral claims must have eligibility verified using an approved provider, and an eligible patient. Once the 340B covered entity validates and approves the referral claim from a patient definition perspective, the 340B TPA will validate that other claim criteria has been met, captures the claim and returns the savings to the covered entity. No matter which process the 340B covered entity uses - manual, their TPA's system or a consultant - the capture of referral claims needs to be clearly stated in the 340B covered entity’s policies and procedures.

Referral Claims can be complex and that is why it is important to set up your program correctly and compliantly to capture 340B referral claims that may render much-needed savings back to your organization.

Have questions or need help? Contact us or learn more about Referral Capture.

The content in this blog is for informational purposes only and is not intended to be used in place of regulatory guidance. The opinions and views expressed herein are those of the authors and do not necessarily reflect the official position or opinions of SUNRx or any regulatory authority. Furthermore, some content may contain copyrighted material, the use of which has not always been specifically authorized by the copyright owner, but which we believe constitutes a "fair use" of any such copyrighted material as provided for in Section 107 of the US Copyright Law. We are making the information herein available in our efforts to advance understanding of the 340B program and its offerings. These views are always subject to change, revision, and rethinking at any time and may not be held in perpetuity.