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Optimize 340B Program Savings & Compliance With Data Mining

Since late 2019, VytlOne has supported the 340B programs of 33 health systems and 38 health centers. Altogether, we’ve generated nearly $1 billion in pharmacy-related savings for our clients. We analyze 340B program-savings potential for dozens of prospective clients every year. And not once have we ever served, or encountered, a health system capable of optimizing its 340B program revenue with in-house personnel and technology. 

Why? Effective data mining for 340B program optimization takes customized software and extraordinarily seasoned professionals. 340B Services Manager Logan Bailey explains: “I’m not aware of any 340B program management software even remotely competitive with ours — either in the depth or breadth of its automated capabilities — and yet, a significant component of our team’s weekly support services is still manually reviewing our clients’ 340B data for missed opportunities.”

“The most common problem we encounter in mismatches leading TPAs to not qualify fills,” continues Operations and Services VP Heather Brooks, “is in the original documentation. As much as AI has advanced in recent years, the technology simply hasn’t reached a point where it catches a high percentage of those errors. Which means that, every day, our team members are going into clients’ EMRs and manually qualifying mismatched claims.”

Missed 340B opportunities: A common scenario

“We recently mined 340B data for a prospective client, a small health system with 175 beds,” says Senior VP of Enterprise Growth Howard Hall. “What we found was fairly shocking to them, but hardly out of the ordinary. They had $26 million in 340B-eligible prescriptions filled, and fully $17 million of that had not been captured for savings. That’s a revenue leakage rate of over 65%. Revenue that the hospital could have invested into expanding and enhancing its healthcare services, while better supporting its community’s most vulnerable patients — which is exactly how every 340B health system we serve invests its 340B revenue.”

Of that mismatched $17 million, he notes, “we could likely claim up to 2/3 for 340B savings,” or $11,322,000. “However, we make it a policy to under-promise — so we estimated to them that we could generate an additional $8 to $9 million in 340B revenue, just from the fills in their system at that time.”

Common causes of 340B data mismatches 

One of the most common causes of 340B misqualifications is Date Of Birth inconsistency, which happens when providers within a system record different dates. Another common cause is mismatched Patient Name entries. For instance, a patient registered as Bill in the pharmacy system may be identified as William by the entity. 

It goes without saying that the more complex a health system’s 340B program is (IE: multiple EHRs, child sites, clinics and pharmacies), the likelier it is that the system’s data submission process will generate errors — leading to missed EHR encounters and, with them, missed 340B savings opportunities.

Technology-related 340B data mismatches 

Monitoring a 340B program, both for compliance and for missed opportunities, becomes even more complicated when a health system uses multiple TPAs. Every TPA’s software system’s interface is unique. So whenever 340B administrators switch back-and-forth between TPA portals, there’s a level of reorientation that takes place — and that can naturally lead to inadvertent form-filling errors. Particularly among in-house 340B personnel with limited experience, and comparatively primitive technology.

The critical importance of 340B-specific software

VytlOne’s 340B team literally couldn’t operate without the 340B PRO software we first deployed in 2019. Thousands of hours and hundreds of combined years of experience went into that first version. Today, we employ nearly 30 programmers, data analysts and underwriting experts — all of whom work closely with our 340B account managers in adapting to the ever-changing 340B landscape. The sheer amount of manpower involved in keeping our software current should give you some idea of just how complex 340B program optimization is.

For Further Reading:
Empower Your Health System’s 340B Program With Analytics
Specialized Software Can Only Do So Much For 340B Programs
Overcome 340B Restrictions With Software And Human Insight

The all-too-human problem limiting 340B savings optimization

“The simple truth,” says Howard, “is that, very often, providers just don’t have the time to worry about 340B. And, just as importantly, they lack the necessary training to take advantage of the savings available. Which is why Education is such a core component to the ongoing support we offer our hospitals and their providers.” Logan agrees. “When clients have simple questions, I routinely respond to texts and emails right up until bedtime. Honestly, on some level I’m never not thinking about 340B — and if I can answer a simple question at night, it saves me that much more time the next morning. 

“We routinely remind our doctors that when patients need medication counseling, we have pharmacists available to help — particularly in health systems where we also own or operate on-campus pharmacies. We try to keep an open dialogue with the physicians we serve at all times. Here’s the thing: When you have meaningful, personalized dialogue with patients, they’re a lot likelier to get their meds and take them as prescribed. Which means they’re then a lot likelier to get better, and not be readmitted. When that happens, they’re also likely to come back to your pharmacy as a repeat customer and patient in the future.

“Everyone at VytlOne’s pharmacies is trained to take whatever time patients need. Whereas you go to a typical chain pharmacy, they’re just trying to get patients in and out as quickly as possible. We take the time to get to know our patients / customers, and actually help them when they need us.”

A brief overview of our 340B data mining process

The first step in mining 340B data is to pull all necessary info from a hospital’s Escribe Data, which is in its EMR prescription files. That data includes all prescribes leaving the hospital, and not all of them have the same data. All prescribes should include what was written, the quantity of each prescription, and where it was sent. The data also includes prescriptions that weren’t filled, which is another reason why TPA data doesn’t always match.

When it comes to value attribution, or determining the potential net revenue for unmatched prescriptions, we talk a lot about visibility. Our software is what gives us that visibility. It’s what enables us to mine data for more opportunities.

Searching for 340B contract pharmacy partners
Part of what we do in mining a health system’s data is searching for potential new contract pharmacies that our clients can add to their 340B networks. Whether they’re small independent pharmacies or large chain operations, if they’re not contracted with us, they’re opportunities for our clients to expand their networks.

On average, the number of 340B contract pharmacies we’ll add to the network of a new client is anywhere from five to ten. Interestingly enough, we routinely identify solid contract relationships with 340B pharmacies located within walking distance of the hospitals we serve. For one health system’s network, we’ve added more than thirty 340B contract pharmacies. 

For Further Reading:
Your Hospital’s 340B Contract Pharmacy Network Is Not What It Should Be.

Adjusting claims to 340B ESP and other manufacturer restrictions
Whenever we come-across prescriptions with manufacturers using the 340B ESP website, we sift out any claims that haven’t been correctly designated. A quick note on 340B ESP: Our team has spent countless hours developing and re-developing tactics and strategies for successfully dealing with drug manufacturer restrictions — 340B ESP or otherwise. For tips you can use in your own 340B program, refer to the following articles:
7 Steps For Overcoming Restrictions on 340B Drug Pricing
Overcome 340B Restrictions With Software And Human Insight

Conducting Opportunity Audits
’I actually had a hand in developing this functionality,” Logan notes. “It’s what enables us to conduct opportunity audits, which we do for all clients and prospects. 

“With a pro tool that filters data, our Pharmacy Claims reviewers can go into EMRs for eligible encounters. Namely, the ones where their TPAs fail to find the encounters. Some TPAs won’t explain why they don’t qualify claims, but we have enough combined experience on our team to figure-out why on our own. Every week, we manually pull this data for our clients, and we sort through the values. We’ll take out the Medicaid prescriptions and the exclusions, then do a profitability analysis — which is Total Revenue minus dispense fees and drug costs. You have to check profitability logic on each prescription. You have to ensure that a claim will be profitable. When we determine that it is, we’ll resubmit the claim to the TPA.”

For Further Reading:
How, and Why, TPAs Misqualify 340B-Eligible Prescriptions
Which TPAs Are The Best In Optimizing 340B Savings And Revenue?

How Can VytlOne Help Your Health System?

To learn more, contact Howard Hall any time. C: 214.808.2700 | howard.hall@vytlone.com

VytlOne

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VytlOne offers hospital systems proven solutions for optimizing pharmacy services’ positive impact on the continuum of care; solutions ranging from management of 340B prescription-savings programs, Retail and Specialty Pharmacy operations, to Prescription Benefits program management, patient financial assistance and Readmission Reduction programs.

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Posted by: RXinsider Staff

RXinsider is a multimedia publishing and technology company offering print publications, digital platforms, events, and content creation services to the B2B pharmacy market.

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