Optimizing Your 340B Program: Ensuring Accurate Capture and Identifying Data Gaps

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The 340B Drug Pricing Program offers significant savings to eligible healthcare organizations, enabling them to stretch scarce resources further and provide better services to their communities. However, ensuring your program captures the maximum potential savings and operates optimally requires close monitoring of data. Below are actionable strategies to enhance your 340B program, validate data accuracy, and identify potential gaps.

Collaborate with Your Third-Party Administrator (TPA)

In-House Pharmacies

For organizations with in-house pharmacies, one of the most beneficial practices is to compare the total claims processed against those captured under the 340B program. This review gives a clearer understanding of your true 340B capture rate. If your organization doesn’t have an in-house pharmacy, consider partnering with a contracted pharmacy to conduct these reviews using the provider file from your Covered Entity (CE).

Key Data Review Elements

1. Electronic Medical Records (EMR) and Electronic Prescribing (ERX) Systems
   • Ensure data is sent daily, and monitor file sizes for consistency. For example, file sizes may vary, with Mondays often seeing fewer entries due to weekend downtime. Regularly monitoring these patterns helps spot any discrepancies early.
2. Location Codes
   • All locations must be accurately represented to connect claims to eligible sites. Regular communication about any location changes is crucial. CEs should update the HRSA website and inform their TPA to avoid losing capture or inadvertently processing ineligible claims.
3. Provider File Accuracy
   • Confirm that all providers—employed, credentialed, or contracted—are present in the TPA’s system with correct start dates. If a pharmacy processes DEA numbers, ensure these can be crosswalked to the corresponding NPI for accurate claims processing.
4. Denial Clarification Codes
   • Some Managed Care Organizations (MCOs) require denial clarification codes during claims adjudication. Missing these codes can lead to blocked claims and potential losses in 340B capture.
5. Manufacturer Blocks
   • Confirm that manufacturer blocks are applied correctly. Failure to validate 340B pricing may result in loss of capture. If the 340B account has the PHS contract, the facility should be able to purchase products at the 340B price.

Collaborate to Confirm Data Accuracy

After confirming the above data points, it’s essential to dive deeper into uncaptured claims to understand why they weren’t eligible for 340B pricing.

In-House Pharmacy Review

With the ability to review all claims processed, start by selecting claims processed through a provider tied to your CE. For any uncaptured claims, verify whether the patient’s encounter can be located in your EMR/ERX system, and ensure the data was properly transmitted to your TPA.

Contracted Pharmacy Review

Two options can be pursued to confirm data accuracy in a contracted pharmacy setup:

1. Claims Review
   • Examine claims that were processed but not captured under 340B due to missing EMR/ERX data. Confirm the patient’s encounter in the EMR/ERX and ensure this information was correctly sent to your TPA.
2. E-Prescriptions Analysis
   • Focus on an ERX routed to a contracted pharmacy that appears in non-captured claims. This option, while more labor-intensive, will yield a clearer understanding of data accuracy and potential omissions.

Closing Data Gaps

If you notice that encounters or e-scripts do not appear captured, verify that the EMR/ERX data was successfully sent to your TPA. Provide them with the file name containing the relevant encounter to investigate the reasons for non-linkage, and resolve any issues.

Key Areas to Investigate

1. Location Misalignment
   • Locations may be inaccurately crosswalked in the files. Confirm that department and location codes are correctly listed.
2. Provider Selection Errors
   • Providers might select incorrect locations during encounters. Review past encounters to ensure providers are choosing the correct settings.
3. EMR/ERX File Omissions:
   • If the issues lies with missing data in your EMR/ERX, consult your vendor to identify the cause and rectify any issues.

Ensuring optimal 340B capture requires a comprehensive approach that emphasizes collaboration, accuracy, and vigilance in data management. By regularly reviewing your program setup and maintaining close communication with your TPA, you can identify gaps and take corrective actions, ultimately maximizing your organization’s 340B savings. Regular audits and open lines of communication not only safeguard your 340B status but also enhance the quality of care provided to your community.

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