Referrals in the 340B Program is, and has been, a hot topic for a number of years in the 340B Drug Program but with the recent ruling in the Genesis v. HRSA case, it’s made another big comeback in the minds and hearts of everyone in and around 340B.
But what referrals are, why, when, and where should you use them, and most importantly, how do you utilize referrals inside of your 340B Program is what many people are talking about, and that’s what we’re going to touch upon today.
By no means will we be able to touch upon every single detail about and around referrals, especially in 340B, but we’re going to go over some of the more general information and things to consider.
What?
In 340B, a referral typically is the process by which a covered entity directs a patient to an outside healthcare provider or facility for services that are not available (or not feasible) to be provided within the covered entity itself.
When a covered entity refers a patient to an external healthcare provider, it might be for services such as specialty care, diagnostic testing, or other medical procedures not offered onsite.
Covered entities might even need to refer patients to other healthcare providers or facilities due to geographic constraints, like many rural entities in 340B regularly face when specialized services are not available locally.
Why?
The referral process is a way for covered entities to ensure that their patient receives comprehensive care, even if certain services are not available within the entity. Many covered entities, especially smaller community health centers or outpatient clinics, may not have the resources to provide a wide range of specialized medical services. In these instances, referrals play a vital role to allow patients to access necessary care from external providers or facilities.
Within 340B, referral prescriptions provide another way for covered entities to access greater savings allowing them to better enhance the patient care that they can provide. However, it is important to note that the 340B Program has specific guidelines and requirements for ensuring your referral prescriptions are truly 340B eligible, and that they align with the overall goal of enhancing healthcare services for the most vulnerable and underserved populations.
When?
Referrals can be done almost any time and in many different patient care situations, but determining when it’s right to add referrals into your 340B Program can be a tricky question to answer.
As soon as you start thinking about referrals in 340B, you need to make sure that you already have a developed, strong relationship with healthcare professionals, specialists, and other entities in your community. Referrals foster collaboration between healthcare providers and this collaborative approach helps to build a network of care that benefits the community and strengthens the overall healthcare ecosystem.
Collaborative care models that include various healthcare providers working together to improve patient outcomes help to facilitate seamless communication and prescription coordination.
To leverage 340B in referral prescriptions, providers need to ensure that their covered entity maintains the care for their patient, which in referrals can present its own unique challenges.
Streamlining communications and prescription management using electronic health records is one way to help your facility in tracking patient referrals out, coordinating prescriptions, and identifying missing records to close the referral loop, therefore helping to utilize these records for 340B eligibility.
Where?
Almost any covered entity can access the benefits, inside and outside of 340B, of a robust and properly run referral program. However, there are some things you will need to consider in order to discover where it makes sense to run referrals through your 340B Program.
If you don’t have a way to document referee provider notes back into your own patient records (in order to demonstrate that you are “maintaining care” for the patient), that might be a reason to press pause and not start referrals quite yet. Even once you do have the means to capture the information that you need, maybe you don’t have the staff to spend time auditing all the new 340B eligible claims.
You know best what your facility is and isn’t capable of, but having someone on your side, even helping you do the work to close that referral loop and track down referee provider files, is never a bad idea. The good news is that in today’s healthcare landscape, there are quite a few companies that not only specialize in closing that gap, but specifically doing so inside of the 340B Program.
How?
Whether you engage an outside company to help with running your 340B referral program or not, your facility’s staff will still be critical to 340B referral success. Making sure that you equip your providers and staff with the necessary knowledge about the 340B Program and its implications for referral prescriptions is going to be essential.
The absolute best way to ensure everyone is on the same page (and to protect yourself in case of a HRSA audit) is to make sure your 340B Policies & Procedures thoroughly describes and covers the full process of what you’re doing to consider a referral prescription as 340B eligible and how you’re going to determine that you “maintain care” at your facility for that patient. This includes clearly defining your checks and balances for how and when you consider someone a “patient” of your covered entity, as the recent Genesis v. HRSA ruling highlighted the importance of for all of 340B.
As Always, Compliance:
No matter what you choose to do with referral prescriptions in your 340B program, you need to always ensure that you’re conducting regular internal audits to ensure that you’re compliant with 340B program standards and statutes. Close monitoring and quick addressing of any deviations from the program requirements helps you to maintain the integrity of your 340B referral program more easily and safeguards you against potential issues.
In addition to internal audits, make sure that you’re also getting a full external audit of your entire 340B Program by a third-party provider at least once annually.
Because we realize that the importance of keeping a close eye on compliance is essential for any 340B Program, we do audits at least twice a year. Additionally, it’s why we review 100% of your 340B captured claims against best practices, industry standards, and HRSA statute, and we include review of your Policy & Procedures in all of our audits. It’s just one more thing we do so you can know that your program is being run correctly, is fully inclusive, covers all requirements, and meets HRSA’s expectations, throughout the year and especially as the industry experiences changes.
In Conclusion
Referrals are an incredible way to improve patient care, but there are many things that any individual covered entity needs to review in order to determine if referrals, especially inside of 340B, are something that would be beneficial for their entity. Most entities can see a significant increase in (compliant) 340B savings captured when they properly add in referrals.
If you’re not sure how to start a review to add referral prescriptions to 340B, or exactly what steps you need to take to get referrals started in your 340B Program, reach out to us. We can not only help with referrals, but all of your 340B Program needs and questions.
Schedule your consultation call with us, Email our CEO directly at Lyssa@optimal340b.com, or call us at 866-OPT340B (648-3402) to get more information about our services and how we can help you get: A Better 340B. For You. For Your Community.
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