The Challenge
The biggest challenge for managing and optimizing a compliant 340b drug program is the fragmentation of data used to determine eligibility and the management of virtual inventories. Two major contract pharmacies chains have "forced" covered entities to use captive processors, giving the retail pharmacy giants an element of control over the eligibility process and further fragmenting the dispensing data. Covered entities are forced to determine 340b eligibility and benefit from 4 or more third party processors. The fragmentation of processors and number covered entity data feeds makes it very difficult for the covered entity to determine if they are being paid on only eligible scripts and effectively manage their program.
Background
Third party processors will contract with covered entities in order to capture the 340b benefit for scripts written at contract pharmacies. The process is done by the covered entity delegating eligibility determination to the third party processor. The third party processor determines eligibility through a high likelihood matching process. Using admit and discharge feeds ("ADT"), the processor accesses fill data from contract pharmacies and matches the eligible prescriber, eligible patient and eligible location with the prescriptions filled by the relative contract pharmacy. A processor may use as many as 6 to 8 incoming feeds from the covered entity to create a highly likely match for the prescriptions filled by any given contract pharmacy.
The Solution
Covered entities should determine qualifying prescriptions at the moment the prescription is written and submit only the prescriptions that meet eligibility criteria. However, this is easier said than done, do to the disparity of systems deployed by the covered entity, processors and contract pharmacies. We have developed a automated, intelligent tool that creates a common data source that can identify only scripts that meet the OPA guidelines, allowing covered entities to submit only prescriptions written by an eligible provider, to an eligible patient from and eligible location.
The tool can further demonstrate a 100% compliance with HRSA program requirements by connecting the filled prescription with the encounter documented in the covered entities medical record.
"You can delegate 340b prescription eligibility but you can't delegate the responsibility or liability."
Results
By aggregating the data feeds into a common database, the covered entity can identify the eligible prescriptions the processor's determined in-eligible. For example, one of our clients identified eligible scripts that were determined to be in-eligible by the third party processor. Upon investigation, these scripts were only determined in-eligible due to the processor's pricing tables not being updated causing the relative NDC to return void. The impact of this discovery resulted in hundreds of thousands of revenue that would never have been discovered or realized by the covered entity.
Additionally, the tool can improve capture rate by determining leakage outside the covered entities contract pharmacy network and provide strategic locations to expand the covered entity's network.
If you would like to learn more, please contact us @ 340b@vertical-healthcare.com
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