Join us as Matthew Krah walks through best practices for maintaining a 340B Third-Party Administrator (TPA) program. We cover how TPAs help ensure compliance, manage claims, and streamline contract-pharmacy networks - plus key red flags to watch out for. If you run or support a 340B covered entity, this episode gives you practical insights to avoid pitfalls and stay audit-ready.
Matthew Krah is a 340B expert with nearly two decades of experience in clinical and business settings. He serves as Senior Solutions Engagement Director for Verity Solutions, a Seattle-based 340B TPA. Prior to joining Verity, he worked at a major academic health system in central Pennsylvania. As 340B Program Manager, he gained experience in mixed-use, retail, and specialty contract pharmacy and revenue cycle management, making him well suited to serve as a 340B subject matter expert for Verity clients. He holds a Master of Science in Healthcare Management from King’s College in Wilkes-Barre.
00:00:00.017 --> 00:00:03.177
In this episode of 340 Banter, we're joined by Matthew Kraw,
00:00:03.597 --> 00:00:05.517
Senior Solutions Engagement Director
00:00:05.517 --> 00:00:09.457
at Verity Solutions, a third-party administrator in the 340B program.
00:00:09.797 --> 00:00:14.137
Today, we delve into TPA housekeeping and reviewing the different elements that
00:00:14.137 --> 00:00:18.117
covered entities need to perform regular maintenance and upkeep on to ensure
00:00:18.117 --> 00:00:21.117
an optimized and compliant 340B program.
00:00:30.017 --> 00:00:30.537
Thank you.
00:00:41.269 --> 00:00:45.009
Let's talk TPA housekeeping and maintenance. I know that many covered entities
00:00:45.009 --> 00:00:48.369
have to work with more than one TPA at a time,
00:00:48.369 --> 00:00:54.069
and it can be really challenging to make sure that the TPAs continue to work
00:00:54.069 --> 00:00:57.249
properly or that the data continues to interface properly.
00:00:57.509 --> 00:01:02.729
So let's start off there and kind of talk about your experience dealing with
00:01:02.729 --> 00:01:07.629
multiple TPAs and your experience and trying to help covered entities to maintain
00:01:07.629 --> 00:01:12.149
a compliant and optimized program. Yeah, I came from a health center.
00:01:12.389 --> 00:01:16.709
We had five TPAs. So it's a lot of data coming in.
00:01:16.829 --> 00:01:21.429
And I'm coming in from a retail background and didn't know what I was looking at.
00:01:21.549 --> 00:01:26.349
So it was a big learning curve trying to interpret all the data. Yeah.
00:01:27.397 --> 00:01:32.077
One of the big things is the data is very different depending on what TPA you're looking at.
00:01:32.277 --> 00:01:35.657
That's a full-time job to manage five TPAs. Yeah.
00:01:35.897 --> 00:01:39.237
Luckily, we had a full-time person. We were fortunate because of the size of
00:01:39.237 --> 00:01:42.277
our health center, but a lot of health centers don't have that.
00:01:42.477 --> 00:01:46.897
And it can be a lot, even before you start talking about auditing,
00:01:47.477 --> 00:01:53.017
just managing the data and getting it compiled for the finance team into one
00:01:53.017 --> 00:01:56.837
manageable file is challenging every month.
00:01:56.837 --> 00:01:59.877
And that's from a health center perspective. From a hospital perspective,
00:02:00.137 --> 00:02:05.437
you toss in having to manage, different crosswalks and package sizes
00:02:05.437 --> 00:02:07.037
and billing units and all of that.
00:02:07.377 --> 00:02:10.417
GPO provisions and all of that. Yeah, that's a lot.
00:02:10.637 --> 00:02:15.857
Yeah. And I think one of the challenging points from a vendor perspective is
00:02:15.857 --> 00:02:19.197
when customers are on the set it and forget it type of mentality. Right.
00:02:19.937 --> 00:02:23.817
So 340B runs itself, doesn't it? It does. There's no hiccups ever.
00:02:23.937 --> 00:02:26.777
Nothing ever changes. It's very status quo.
00:02:27.817 --> 00:02:31.817
But, what we've done, the approach we've taken is we do a business
00:02:31.817 --> 00:02:32.997
review for all of our clients.
00:02:33.177 --> 00:02:36.857
So if you participate in it, awesome, right? We want you to participate.
00:02:37.197 --> 00:02:40.517
If you don't participate in it, we're still doing that business review and we're
00:02:40.517 --> 00:02:42.337
storing it in our CRM system.
00:02:42.717 --> 00:02:46.177
Is that like when they come on board or quarterly or monthly?
00:02:46.617 --> 00:02:48.337
Bi-weekly. Oh, wow. Okay. Yeah.
00:02:48.877 --> 00:02:53.997
And it's typical, like, accumulations, top wax spin,
00:02:54.697 --> 00:02:56.457
data feed errors that we see.
00:02:57.017 --> 00:03:00.297
And it's really nice to have. So, like, in your position, when you take over
00:03:00.297 --> 00:03:03.337
a new position at a health center, right, you could go to your,
00:03:03.497 --> 00:03:05.417
if you were using Verity, come to us and say, hey,
00:03:05.497 --> 00:03:08.137
what have been the last six months of business reviews looked like?
00:03:08.377 --> 00:03:11.937
And at least that helps bring you up to speed if nobody else was actually paying attention.
00:03:12.777 --> 00:03:15.777
So set it and forget it, I think, is one of the biggest challenges.
00:03:16.257 --> 00:03:19.757
And other challenges, some of our legacy customers might be using an old data
00:03:19.757 --> 00:03:22.157
spec, right? So if you wrote a data spec in 2016.
00:03:23.139 --> 00:03:26.059
Well, a lot of things have changed back then, and we've got a lot of optional
00:03:26.059 --> 00:03:29.659
fields in our data spec, so you're not getting the full advantage of all of
00:03:29.659 --> 00:03:32.039
our audit report fields if you don't have everything in there.
00:03:32.339 --> 00:03:36.679
I imagine in that time, even the EMR fields would change as well,
00:03:36.719 --> 00:03:37.839
the medical record fields.
00:03:38.199 --> 00:03:44.219
I've seen people that didn't fix their EMR feeds, and they have new sites that
00:03:44.219 --> 00:03:45.779
aren't feeding into their PPA.
00:03:45.779 --> 00:03:50.139
New locations or new encounter types that aren't coming over in the files
00:03:50.139 --> 00:03:55.679
if it's been almost 10 years since they set up the feed with the data spec. Yep.
00:03:55.959 --> 00:03:59.539
And I think there's a different philosophy on those locations, right?
00:03:59.619 --> 00:04:03.199
Like, so some of them, some of our customers just do their own filtering before
00:04:03.199 --> 00:04:04.439
the data even comes to Verity.
00:04:04.579 --> 00:04:06.619
And then others are using our location filtering.
00:04:06.899 --> 00:04:09.179
Now, what's kind of nice if you're using our location filtering,
00:04:09.319 --> 00:04:12.779
at least you can see there's 200 locations that aren't
00:04:12.839 --> 00:04:15.639
crosswalked and are showing as an active. So that might be like a little trigger
00:04:15.639 --> 00:04:17.159
of like, okay, maybe we should do something.
00:04:17.339 --> 00:04:20.699
But more challenging if they're filtering ahead of time, but they don't necessarily
00:04:20.699 --> 00:04:23.939
know that they're filtering new ones out.
00:04:24.059 --> 00:04:26.919
And at least with health centers, they often don't have...
00:04:27.982 --> 00:04:32.602
If they have IT departments, they're not very expansive. So it's hard for them
00:04:32.602 --> 00:04:36.442
to identify those challenges in their data feeds.
00:04:36.802 --> 00:04:42.722
We actually had a situation recently where one of the EMRs was filtering all
00:04:42.722 --> 00:04:48.322
Medicaid encounters for all of the patients. So if you were registered as Medicaid,
00:04:48.322 --> 00:04:50.522
they weren't even sending us those encounters.
00:04:51.422 --> 00:04:55.342
And the problem with that is, was Medicaid actually used at the pharmacy at
00:04:55.342 --> 00:04:58.502
point of sale, right? So we don't need to be actually carving that patient out.
00:04:59.122 --> 00:05:02.902
So again, without actually looking into the why are we filtering
00:05:02.902 --> 00:05:04.502
this? Why are we not sending this?
00:05:04.902 --> 00:05:07.722
You could really be losing out on a lot of opportunity. And,
00:05:07.842 --> 00:05:11.482
I think it was on Halloween we got that nice surprise from the government
00:05:11.482 --> 00:05:14.682
that medical claims are now included with the rebate.
00:05:15.002 --> 00:05:16.502
And that's referred to me rebate, yeah. Well, guess what we had to do?
00:05:16.582 --> 00:05:19.442
We had to update our data spec in Verity to be able to digest that.
00:05:19.682 --> 00:05:23.522
And if you're not looking at your data spec and asking your TPA what changes
00:05:23.522 --> 00:05:25.662
are coming, should I reevaluate this?
00:05:26.281 --> 00:05:29.081
We're not going to be able to help you submit medical claims if we don't have
00:05:29.081 --> 00:05:30.721
that HICS-PICS and unit of measure data.
00:05:30.721 --> 00:05:34.661
And even that, I think, is challenging for some covered entities,
00:05:34.981 --> 00:05:40.241
just the elements for the 340B rebate piece, looking at
00:05:40.301 --> 00:05:44.401
the HCPCS and unit of measure are probably relatively easy to pull through.
00:05:44.401 --> 00:05:52.961
However, the claim line number is not something that necessarily is accessible or sendable,
00:05:53.101 --> 00:06:00.081
but it is a field or a value that needs to be present in order for the claim
00:06:00.081 --> 00:06:01.781
to pass that front-end validation.
00:06:02.181 --> 00:06:06.921
So being able to then speak to your vendor to say, okay, if this isn't something
00:06:06.921 --> 00:06:10.601
that we have, how can we work to have it populate? You know,
00:06:10.741 --> 00:06:16.181
it needs to have a digit and needs to have an integer in that field.
00:06:16.441 --> 00:06:19.981
And as long as you can trace back that claim, because that's what that claim
00:06:19.981 --> 00:06:24.841
line number would indicate, as long as you can trace it back or it's identifiable,
00:06:24.841 --> 00:06:26.521
you can kind of work through that.
00:06:26.641 --> 00:06:33.161
But being able to work with your TPAs, plural, to make sure that you've got
00:06:33.161 --> 00:06:37.221
that information both going in and coming out is important. I didn't like working
00:06:37.221 --> 00:06:40.221
with three when I had to, so I couldn't imagine working with five.
00:06:40.641 --> 00:06:48.641
I quickly downsized as quickly as possible, and we still have three at my health center.
00:06:48.841 --> 00:06:55.041
So it's challenging, but sometimes you don't have a choice or you come in and
00:06:55.041 --> 00:07:00.741
there's some of those older legacy TPAs that you struggle to get rid of.
00:07:00.741 --> 00:07:06.341
But yeah, it creates challenges and it's really important that you think about that.
00:07:06.481 --> 00:07:11.101
And when you're staffing your 340B program is that you have to be able to manage
00:07:11.101 --> 00:07:15.661
all that data coming in and it can create some additional staff.
00:07:16.396 --> 00:07:19.236
Workforce. I think another great example we have of
00:07:19.356 --> 00:07:24.936
data being filtered out on the hospital side is billing for waste. Yes.
00:07:25.516 --> 00:07:28.496
And that's important with the rebate model too. It's going to be big for the
00:07:28.496 --> 00:07:32.336
rebate model. It's going to be big for 340B and it's huge for reimbursement.
00:07:32.436 --> 00:07:35.036
So it's going to be really like a three-way hit if you're not getting that. Yeah.
00:07:35.396 --> 00:07:38.816
And I often say that we can bring the drug in at 340B all day long,
00:07:38.956 --> 00:07:41.596
but if you're not getting paid for it what good is it? Yeah.
00:07:41.756 --> 00:07:44.696
And we've, we had a scenario where one of our customers
00:07:44.696 --> 00:07:47.636
was buying a ton of ramecade on whack
00:07:47.636 --> 00:07:50.656
like 90 of it and it was small
00:07:50.656 --> 00:07:53.416
doses it was a pediatric unit and what was happening
00:07:53.416 --> 00:07:58.036
was there's just a lot of waste so we worked with them did like nine-month reconciliation
00:07:58.036 --> 00:08:03.756
got a data upload of all those claims and then like their 340b went
00:08:03.756 --> 00:08:07.516
through the roof because they had all that backing of the waste, so waste
00:08:07.516 --> 00:08:10.876
is really something that i would also say like look into it what's your waste
00:08:10.876 --> 00:08:12.936
policy? Work with your revenue cycle director.
00:08:13.156 --> 00:08:16.096
Are you actually billing for waste? Are you putting the right modifiers on it?
00:08:16.456 --> 00:08:19.516
So there's a lot beyond just the getting the drug in at the best price.
00:08:19.616 --> 00:08:21.956
We really need to make sure we're getting paid for it as well.
00:08:22.236 --> 00:08:26.136
And I mean, along with that is, some people will view that as,
00:08:26.256 --> 00:08:30.636
oh, well, that's us working the system or getting away with something, but it's not.
00:08:30.836 --> 00:08:33.856
You just have to make sure you have the accountable or excuse me,
00:08:33.936 --> 00:08:38.696
the records to be able to demonstrate or back up the 340B behind it.
00:08:38.896 --> 00:08:42.036
It's definitely within the rule set my background
00:08:42.036 --> 00:08:44.836
prior to to 340B, I did
00:08:44.836 --> 00:08:47.736
a few years in the revenue cycle and you know it's definitely
00:08:47.736 --> 00:08:52.456
permitted by cms using that ud modifier there's policies out there that are
00:08:52.456 --> 00:08:56.076
publicly available pretty easy to find with a google search look at your top
00:08:56.076 --> 00:08:59.496
payers you know if you're an area that's dominated by a blue you know look up
00:08:59.496 --> 00:09:03.276
that local blue and what's their policy on waste billing and most likely it's
00:09:03.276 --> 00:09:06.356
going to follow what cms says put your medical jws yeah.
00:09:07.133 --> 00:09:11.013
Or JW, thank you for correcting me on there. He was like, that's Medicaid.
00:09:11.193 --> 00:09:14.213
That's wrong. Yeah, I got my modifiers mixed up.
00:09:14.693 --> 00:09:21.293
Yeah, I think that's really important because sometimes the waste is not unavoidable
00:09:21.293 --> 00:09:25.853
because of dosages. So you might as well be doing that documentation.
00:09:25.953 --> 00:09:31.093
But I think that that really brings up a good point that 340B is not a pharmacy program solely.
00:09:31.093 --> 00:09:35.553
It requires working together with your finance team, your billing team,
00:09:35.733 --> 00:09:41.113
your IT and EMR teams, that you really have to get everyone together so you
00:09:41.113 --> 00:09:43.373
can manage that program completely.
00:09:43.373 --> 00:09:46.913
And that goes for the TPA as well, because you have these data feeds.
00:09:47.193 --> 00:09:51.773
And maybe it's a nursing manager that's making sure that those waste codes are
00:09:51.773 --> 00:09:56.853
being put in there correctly. Yeah, I'm a big fan of a well-staffed steering
00:09:56.853 --> 00:09:58.473
committee for the 340B program.
00:09:58.953 --> 00:10:01.833
In one area you missed, too, I think government affairs. I think that's really
00:10:01.833 --> 00:10:05.153
important to have at the table. Like, let's be proactive with this stuff and
00:10:05.153 --> 00:10:06.333
let's not wait till there's a crisis.
00:10:06.993 --> 00:10:09.653
And finance can help with that. Revenue cycle can help with that.
00:10:10.033 --> 00:10:13.793
So I think it's definitely a multidisciplinary approach for a really strong,
00:10:13.933 --> 00:10:16.053
successful 340B IT as well.
00:10:16.213 --> 00:10:20.653
You know, have an IT at the table. So thinking about the entities that may be
00:10:20.653 --> 00:10:23.413
struggling or facing challenges with,
00:10:23.914 --> 00:10:28.054
managing their TPAs or they're not sure if they're making, you know,
00:10:28.154 --> 00:10:31.014
they're keeping up on all the data elements. I'm wondering if we can kind of
00:10:31.014 --> 00:10:35.474
go through two lists, more or less, for people to be able to use as takeaways from this.
00:10:35.614 --> 00:10:42.314
One, I'm thinking, is what elements should they be looking at with their TPAs on a regular basis?
00:10:42.594 --> 00:10:47.214
And then when they're selecting a TPA, what questions should they be asking?
00:10:47.354 --> 00:10:50.534
It's tough when you don't know what you don't know. So what things should you
00:10:50.534 --> 00:10:56.754
go in to that negotiation or conversation, hoping to get out in terms of just
00:10:56.754 --> 00:10:59.654
understanding the program to see if it fits your own covered entity.
00:11:00.354 --> 00:11:04.034
So, I mean, I'll start with, you know, one easy thing that I think could be,
00:11:04.374 --> 00:11:07.174
you know, a starting point of where to dig in a little deeper to try to find
00:11:07.174 --> 00:11:11.214
if there's issues with your program is looking at your accumulator and sorting
00:11:11.214 --> 00:11:14.454
by the negatives and anything that's excessively positive.
00:11:14.494 --> 00:11:18.294
Because if we've got excessive positives, that to me says we've got a multiplier
00:11:18.294 --> 00:11:21.194
issue or we don't have a price in our catalog.
00:11:21.214 --> 00:11:25.154
So every order is getting split to GPO or getting split to WAC and not actually
00:11:25.154 --> 00:11:26.494
being purchased on 340B.
00:11:26.754 --> 00:11:29.634
If it's excessively negative, what happened there, right?
00:11:29.754 --> 00:11:33.094
I had a situation once where a pharmacy tech with very good intentions in one
00:11:33.094 --> 00:11:36.994
of our own pharmacies would go into Cardinal and buy a generic equivalent anytime
00:11:36.994 --> 00:11:38.074
something was out of stock.
00:11:38.474 --> 00:11:40.234
Awesome. I love that you're buying the best price.
00:11:40.793 --> 00:11:44.613
But we don't have the accumulations to back that, right? So you gotta make sure
00:11:44.613 --> 00:11:46.213
that you're focusing on that.
00:11:46.413 --> 00:11:49.793
And then when it comes time for shopping for a vendor
00:11:49.893 --> 00:11:52.753
I would say rely on your peer groups, right?
00:11:52.913 --> 00:11:55.433
Don't just take the sales reps word for it.
00:11:55.773 --> 00:11:58.553
Everyone's gonna say that they're the best, but can they actually prove it?
00:11:59.173 --> 00:12:04.813
So use those conferences again, networking, ask for references from who you're evaluating.
00:12:05.173 --> 00:12:09.713
And I think that all TPAs can build a 340B bucket, right?
00:12:09.713 --> 00:12:15.293
But where areas that I think are distinguishable is the amount of support that
00:12:15.293 --> 00:12:18.553
you're going to get from that TPA because after the contract signed,
00:12:18.813 --> 00:12:20.773
what's the quality of implementation like?
00:12:20.893 --> 00:12:24.513
What is the quality of the support that you're going to get after implementation?
00:12:24.853 --> 00:12:29.333
And a lot of that is publicly tracked by external firms outside of the TPAs.
00:12:29.473 --> 00:12:33.573
So class research is one of them. You can go in, you can look at all the TPAs
00:12:33.573 --> 00:12:35.833
and how they stack up against the competition.
00:12:36.693 --> 00:12:41.853
Cybersecurity is another huge one. You know, I myself got like a $30 check from
00:12:41.853 --> 00:12:44.453
a breach that I was involved with from a hospital back in Pennsylvania.
00:12:44.713 --> 00:12:47.633
And that bought me about a muffin and a Starbucks coffee.
00:12:48.793 --> 00:12:53.213
But I mean, it is a real threat. And, you know, you want to know what is your
00:12:53.213 --> 00:12:55.273
TPA doing to keep your data safe?
00:12:55.293 --> 00:12:58.113
Because the last thing you want to do is be on the front page of a local newspaper
00:12:58.113 --> 00:13:00.893
that there was a data breach from your health center or hospital.
00:13:01.426 --> 00:13:04.806
What kinds of things, like how would they, how would a covered entity know that
00:13:04.806 --> 00:13:10.946
their TPA has proper cybersecurity measures in place? So there is certifications
00:13:10.946 --> 00:13:12.126
out there that are available.
00:13:12.666 --> 00:13:19.786
You know, SOC 2 is one that a lot use. That's more of a financial type of cybersecurity certification.
00:13:20.026 --> 00:13:25.526
And then there's HITRUST, which is the more of the healthcare sector type of cybersecurity.
00:13:25.846 --> 00:13:30.526
And Verity has HITRUST certification. I will say that that is one of the more
00:13:30.526 --> 00:13:34.766
challenging and more expensive certifications to get. So, you know,
00:13:34.866 --> 00:13:38.366
you want to know what kind of security measures are in place.
00:13:38.466 --> 00:13:41.466
And that requires us to have all different kinds of policies and procedures.
00:13:42.266 --> 00:13:44.326
Notifying our customers of any breaches.
00:13:44.686 --> 00:13:48.526
They test our staff regularly. We get phishing attempts all the time and we
00:13:48.526 --> 00:13:51.906
have to submit the phishing report and, you know, get a pass or fail and they
00:13:51.906 --> 00:13:53.006
actually track those rates.
00:13:53.526 --> 00:13:57.166
So, you know, getting to know that and then know what kind of cybersecurity
00:13:57.166 --> 00:13:59.066
coverage that they have, right?
00:13:59.486 --> 00:14:02.506
You know, someone can say, oh, we'll give you unlimited cybersecurity insurance.
00:14:02.506 --> 00:14:05.966
But if you don't have the funds to back it, it's really only as valuable as
00:14:05.966 --> 00:14:08.146
the ink that the paper's printed on.
00:14:08.326 --> 00:14:13.046
So, you know, I think that's a pretty good, what's your service like,
00:14:13.126 --> 00:14:17.086
what's your reputation like, and what's your cybersecurity measures?
00:14:17.086 --> 00:14:22.346
And one of the things I've done and I've talked to other covered entities about
00:14:22.346 --> 00:14:24.306
is you mentioned references,
00:14:24.306 --> 00:14:27.126
but it's also valuable if you find references that
00:14:27.126 --> 00:14:33.086
aren't given by the TPA as well and find them through maybe Nautopod for the
00:14:33.086 --> 00:14:39.866
health centers or the 340B health exchange where you can talk to other people
00:14:39.866 --> 00:14:44.266
and covered entities and get a reference that may not be provided from the vendor
00:14:44.266 --> 00:14:45.806
because you'll get more of a,
00:14:45.866 --> 00:14:48.746
possibly more of a, an honest review of the program.
00:14:49.246 --> 00:14:53.486
And I think something I did that's really simple, doesn't require any Excel
00:14:53.486 --> 00:14:56.086
skills because I have very minimal Excel skills.
00:14:57.126 --> 00:15:01.686
When I was looking through the reports, I would do a simple look each month
00:15:01.686 --> 00:15:04.646
at the tracking of the number of claims captured,
00:15:05.190 --> 00:15:09.110
Because I could easily see if there were anomalies and we would have a month
00:15:09.110 --> 00:15:13.670
where we drop 500 claims at a certain pharmacy and I'd know,
00:15:13.930 --> 00:15:14.870
okay, there's a problem here.
00:15:14.990 --> 00:15:19.530
I don't know what it is, but it clued me in so I could ask the questions.
00:15:19.850 --> 00:15:26.070
And that open communication with the vendor partner is really important.
00:15:26.070 --> 00:15:30.210
You may not need to know what the problem is or how to fix it,
00:15:30.290 --> 00:15:34.710
but knowing who to call and start those conversations. Ghostbusters every time.
00:15:35.190 --> 00:15:41.590
So I agree. And I think another easy way to identify where there may be a problem,
00:15:41.730 --> 00:15:46.630
even if you don't know what's causing it, is periodically pulling your electronic
00:15:46.630 --> 00:15:51.030
prescription report from your medical record to see how many prescriptions are
00:15:51.030 --> 00:15:52.370
going out to each pharmacy.
00:15:52.930 --> 00:15:57.070
And while that won't factor in if you carve out Medicaid or you've got manufacturer
00:15:57.070 --> 00:16:02.710
restrictions there, it will provide you with more or less a comparator for month over month.
00:16:02.850 --> 00:16:07.290
We've been sending about this many prescriptions to this pharmacy and we've
00:16:07.290 --> 00:16:08.670
had about this many qualify.
00:16:08.670 --> 00:16:12.670
And if there's a change that's not reflected in the other number,
00:16:13.270 --> 00:16:16.510
then being able to say, OK, is there something wrong with,
00:16:16.590 --> 00:16:19.390
are we are we qualifying based on prescriber NPI?
00:16:19.790 --> 00:16:23.650
Do we need to update the provider list? Are we qualifying based on location
00:16:23.650 --> 00:16:26.030
ID? Do we need to update any locations?
00:16:26.810 --> 00:16:31.990
Kind of using that as a starting place to be able to dig more for a root cause analysis.
00:16:32.370 --> 00:16:35.330
And most TPAs have a feeds monitor of some sort, right?
00:16:35.450 --> 00:16:38.970
So that's one of my go to's as well. Like if I've got a customer that sent us
00:16:38.970 --> 00:16:44.110
20,000 line items overnight and 900 processed, something's wrong there,
00:16:44.250 --> 00:16:45.270
right? We need to fix that.
00:16:45.510 --> 00:16:49.290
So I would also recommend looking at that, too, and see how many of your files
00:16:49.290 --> 00:16:51.890
are actually processing versus rejecting or duplicating.
00:16:52.870 --> 00:16:55.630
Yeah. Well, thanks so much, Matt. It's been really helpful to go through this.
00:16:55.830 --> 00:16:57.930
It's been fun. Thanks for having me. Yeah, it's been great.
"One of the biggest challenges is when TPAs filter locations ahead of time. If you're not aware of it, you might be unintentionally excluding encounter types, and losing out on 340B opportunities."
Meet Logan Yoho, PharmD, BCACP, 340B ACE, and co-host of the 340Banter Podcast. With nearly a decade of experience in the 340B industry, Logan is dedicated to helping health centers optimize and maintain successful, compliant 340B Programs. As Director of Advocacy and Education at FQHC 340B Compliance, he focuses on implementing entity-owned pharmacies and guiding advocacy efforts for 340B. Logan’s extensive background includes leading the pharmacy and 340B programs at Hopewell Health Centers, serving as Apexus 340B University Faculty, and chairing the Ohio 340B FQHC Consortium. Logan’s leadership and expertise have earned him multiple awards, and he brings a wealth of knowledge to every episode of 340Banter.
Meet Chelsea Violette, PharmD, BCACP, 340B ACE, and your co-host for the 340Banter Podcast. With over a decade of experience in pharmacy and 340B Program management, Chelsea brings a wealth of knowledge to the table. As Chief Operating Officer at FQHC 340B Compliance, she works tirelessly to support health centers across the country, ensuring they have the tools and strategies they need to succeed. Chelsea’s hands-on experience as a 340B Consultant and Pharmacy Manager, combined with her expertise as a subject matter expert for the Apexus 340B Prime Vendor Program, makes her a trusted voice in the world of 340B compliance. Tune in for her practical insights, guidance, and lively discussions on all things 340B.
00:00:00.017 --> 00:00:03.177
In this episode of 340 Banter, we're joined by Matthew Kraw,
00:00:03.597 --> 00:00:05.517
Senior Solutions Engagement Director
00:00:05.517 --> 00:00:09.457
at Verity Solutions, a third-party administrator in the 340B program.
00:00:09.797 --> 00:00:14.137
Today, we delve into TPA housekeeping and reviewing the different elements that
00:00:14.137 --> 00:00:18.117
covered entities need to perform regular maintenance and upkeep on to ensure
00:00:18.117 --> 00:00:21.117
an optimized and compliant 340B program.
00:00:30.017 --> 00:00:30.537
Thank you.
00:00:41.269 --> 00:00:45.009
Let's talk TPA housekeeping and maintenance. I know that many covered entities
00:00:45.009 --> 00:00:48.369
have to work with more than one TPA at a time,
00:00:48.369 --> 00:00:54.069
and it can be really challenging to make sure that the TPAs continue to work
00:00:54.069 --> 00:00:57.249
properly or that the data continues to interface properly.
00:00:57.509 --> 00:01:02.729
So let's start off there and kind of talk about your experience dealing with
00:01:02.729 --> 00:01:07.629
multiple TPAs and your experience and trying to help covered entities to maintain
00:01:07.629 --> 00:01:12.149
a compliant and optimized program. Yeah, I came from a health center.
00:01:12.389 --> 00:01:16.709
We had five TPAs. So it's a lot of data coming in.
00:01:16.829 --> 00:01:21.429
And I'm coming in from a retail background and didn't know what I was looking at.
00:01:21.549 --> 00:01:26.349
So it was a big learning curve trying to interpret all the data. Yeah.
00:01:27.397 --> 00:01:32.077
One of the big things is the data is very different depending on what TPA you're looking at.
00:01:32.277 --> 00:01:35.657
That's a full-time job to manage five TPAs. Yeah.
00:01:35.897 --> 00:01:39.237
Luckily, we had a full-time person. We were fortunate because of the size of
00:01:39.237 --> 00:01:42.277
our health center, but a lot of health centers don't have that.
00:01:42.477 --> 00:01:46.897
And it can be a lot, even before you start talking about auditing,
00:01:47.477 --> 00:01:53.017
just managing the data and getting it compiled for the finance team into one
00:01:53.017 --> 00:01:56.837
manageable file is challenging every month.
00:01:56.837 --> 00:01:59.877
And that's from a health center perspective. From a hospital perspective,
00:02:00.137 --> 00:02:05.437
you toss in having to manage, different crosswalks and package sizes
00:02:05.437 --> 00:02:07.037
and billing units and all of that.
00:02:07.377 --> 00:02:10.417
GPO provisions and all of that. Yeah, that's a lot.
00:02:10.637 --> 00:02:15.857
Yeah. And I think one of the challenging points from a vendor perspective is
00:02:15.857 --> 00:02:19.197
when customers are on the set it and forget it type of mentality. Right.
00:02:19.937 --> 00:02:23.817
So 340B runs itself, doesn't it? It does. There's no hiccups ever.
00:02:23.937 --> 00:02:26.777
Nothing ever changes. It's very status quo.
00:02:27.817 --> 00:02:31.817
But, what we've done, the approach we've taken is we do a business
00:02:31.817 --> 00:02:32.997
review for all of our clients.
00:02:33.177 --> 00:02:36.857
So if you participate in it, awesome, right? We want you to participate.
00:02:37.197 --> 00:02:40.517
If you don't participate in it, we're still doing that business review and we're
00:02:40.517 --> 00:02:42.337
storing it in our CRM system.
00:02:42.717 --> 00:02:46.177
Is that like when they come on board or quarterly or monthly?
00:02:46.617 --> 00:02:48.337
Bi-weekly. Oh, wow. Okay. Yeah.
00:02:48.877 --> 00:02:53.997
And it's typical, like, accumulations, top wax spin,
00:02:54.697 --> 00:02:56.457
data feed errors that we see.
00:02:57.017 --> 00:03:00.297
And it's really nice to have. So, like, in your position, when you take over
00:03:00.297 --> 00:03:03.337
a new position at a health center, right, you could go to your,
00:03:03.497 --> 00:03:05.417
if you were using Verity, come to us and say, hey,
00:03:05.497 --> 00:03:08.137
what have been the last six months of business reviews looked like?
00:03:08.377 --> 00:03:11.937
And at least that helps bring you up to speed if nobody else was actually paying attention.
00:03:12.777 --> 00:03:15.777
So set it and forget it, I think, is one of the biggest challenges.
00:03:16.257 --> 00:03:19.757
And other challenges, some of our legacy customers might be using an old data
00:03:19.757 --> 00:03:22.157
spec, right? So if you wrote a data spec in 2016.
00:03:23.139 --> 00:03:26.059
Well, a lot of things have changed back then, and we've got a lot of optional
00:03:26.059 --> 00:03:29.659
fields in our data spec, so you're not getting the full advantage of all of
00:03:29.659 --> 00:03:32.039
our audit report fields if you don't have everything in there.
00:03:32.339 --> 00:03:36.679
I imagine in that time, even the EMR fields would change as well,
00:03:36.719 --> 00:03:37.839
the medical record fields.
00:03:38.199 --> 00:03:44.219
I've seen people that didn't fix their EMR feeds, and they have new sites that
00:03:44.219 --> 00:03:45.779
aren't feeding into their PPA.
00:03:45.779 --> 00:03:50.139
New locations or new encounter types that aren't coming over in the files
00:03:50.139 --> 00:03:55.679
if it's been almost 10 years since they set up the feed with the data spec. Yep.
00:03:55.959 --> 00:03:59.539
And I think there's a different philosophy on those locations, right?
00:03:59.619 --> 00:04:03.199
Like, so some of them, some of our customers just do their own filtering before
00:04:03.199 --> 00:04:04.439
the data even comes to Verity.
00:04:04.579 --> 00:04:06.619
And then others are using our location filtering.
00:04:06.899 --> 00:04:09.179
Now, what's kind of nice if you're using our location filtering,
00:04:09.319 --> 00:04:12.779
at least you can see there's 200 locations that aren't
00:04:12.839 --> 00:04:15.639
crosswalked and are showing as an active. So that might be like a little trigger
00:04:15.639 --> 00:04:17.159
of like, okay, maybe we should do something.
00:04:17.339 --> 00:04:20.699
But more challenging if they're filtering ahead of time, but they don't necessarily
00:04:20.699 --> 00:04:23.939
know that they're filtering new ones out.
00:04:24.059 --> 00:04:26.919
And at least with health centers, they often don't have...
00:04:27.982 --> 00:04:32.602
If they have IT departments, they're not very expansive. So it's hard for them
00:04:32.602 --> 00:04:36.442
to identify those challenges in their data feeds.
00:04:36.802 --> 00:04:42.722
We actually had a situation recently where one of the EMRs was filtering all
00:04:42.722 --> 00:04:48.322
Medicaid encounters for all of the patients. So if you were registered as Medicaid,
00:04:48.322 --> 00:04:50.522
they weren't even sending us those encounters.
00:04:51.422 --> 00:04:55.342
And the problem with that is, was Medicaid actually used at the pharmacy at
00:04:55.342 --> 00:04:58.502
point of sale, right? So we don't need to be actually carving that patient out.
00:04:59.122 --> 00:05:02.902
So again, without actually looking into the why are we filtering
00:05:02.902 --> 00:05:04.502
this? Why are we not sending this?
00:05:04.902 --> 00:05:07.722
You could really be losing out on a lot of opportunity. And,
00:05:07.842 --> 00:05:11.482
I think it was on Halloween we got that nice surprise from the government
00:05:11.482 --> 00:05:14.682
that medical claims are now included with the rebate.
00:05:15.002 --> 00:05:16.502
And that's referred to me rebate, yeah. Well, guess what we had to do?
00:05:16.582 --> 00:05:19.442
We had to update our data spec in Verity to be able to digest that.
00:05:19.682 --> 00:05:23.522
And if you're not looking at your data spec and asking your TPA what changes
00:05:23.522 --> 00:05:25.662
are coming, should I reevaluate this?
00:05:26.281 --> 00:05:29.081
We're not going to be able to help you submit medical claims if we don't have
00:05:29.081 --> 00:05:30.721
that HICS-PICS and unit of measure data.
00:05:30.721 --> 00:05:34.661
And even that, I think, is challenging for some covered entities,
00:05:34.981 --> 00:05:40.241
just the elements for the 340B rebate piece, looking at
00:05:40.301 --> 00:05:44.401
the HCPCS and unit of measure are probably relatively easy to pull through.
00:05:44.401 --> 00:05:52.961
However, the claim line number is not something that necessarily is accessible or sendable,
00:05:53.101 --> 00:06:00.081
but it is a field or a value that needs to be present in order for the claim
00:06:00.081 --> 00:06:01.781
to pass that front-end validation.
00:06:02.181 --> 00:06:06.921
So being able to then speak to your vendor to say, okay, if this isn't something
00:06:06.921 --> 00:06:10.601
that we have, how can we work to have it populate? You know,
00:06:10.741 --> 00:06:16.181
it needs to have a digit and needs to have an integer in that field.
00:06:16.441 --> 00:06:19.981
And as long as you can trace back that claim, because that's what that claim
00:06:19.981 --> 00:06:24.841
line number would indicate, as long as you can trace it back or it's identifiable,
00:06:24.841 --> 00:06:26.521
you can kind of work through that.
00:06:26.641 --> 00:06:33.161
But being able to work with your TPAs, plural, to make sure that you've got
00:06:33.161 --> 00:06:37.221
that information both going in and coming out is important. I didn't like working
00:06:37.221 --> 00:06:40.221
with three when I had to, so I couldn't imagine working with five.
00:06:40.641 --> 00:06:48.641
I quickly downsized as quickly as possible, and we still have three at my health center.
00:06:48.841 --> 00:06:55.041
So it's challenging, but sometimes you don't have a choice or you come in and
00:06:55.041 --> 00:07:00.741
there's some of those older legacy TPAs that you struggle to get rid of.
00:07:00.741 --> 00:07:06.341
But yeah, it creates challenges and it's really important that you think about that.
00:07:06.481 --> 00:07:11.101
And when you're staffing your 340B program is that you have to be able to manage
00:07:11.101 --> 00:07:15.661
all that data coming in and it can create some additional staff.
00:07:16.396 --> 00:07:19.236
Workforce. I think another great example we have of
00:07:19.356 --> 00:07:24.936
data being filtered out on the hospital side is billing for waste. Yes.
00:07:25.516 --> 00:07:28.496
And that's important with the rebate model too. It's going to be big for the
00:07:28.496 --> 00:07:32.336
rebate model. It's going to be big for 340B and it's huge for reimbursement.
00:07:32.436 --> 00:07:35.036
So it's going to be really like a three-way hit if you're not getting that. Yeah.
00:07:35.396 --> 00:07:38.816
And I often say that we can bring the drug in at 340B all day long,
00:07:38.956 --> 00:07:41.596
but if you're not getting paid for it what good is it? Yeah.
00:07:41.756 --> 00:07:44.696
And we've, we had a scenario where one of our customers
00:07:44.696 --> 00:07:47.636
was buying a ton of ramecade on whack
00:07:47.636 --> 00:07:50.656
like 90 of it and it was small
00:07:50.656 --> 00:07:53.416
doses it was a pediatric unit and what was happening
00:07:53.416 --> 00:07:58.036
was there's just a lot of waste so we worked with them did like nine-month reconciliation
00:07:58.036 --> 00:08:03.756
got a data upload of all those claims and then like their 340b went
00:08:03.756 --> 00:08:07.516
through the roof because they had all that backing of the waste, so waste
00:08:07.516 --> 00:08:10.876
is really something that i would also say like look into it what's your waste
00:08:10.876 --> 00:08:12.936
policy? Work with your revenue cycle director.
00:08:13.156 --> 00:08:16.096
Are you actually billing for waste? Are you putting the right modifiers on it?
00:08:16.456 --> 00:08:19.516
So there's a lot beyond just the getting the drug in at the best price.
00:08:19.616 --> 00:08:21.956
We really need to make sure we're getting paid for it as well.
00:08:22.236 --> 00:08:26.136
And I mean, along with that is, some people will view that as,
00:08:26.256 --> 00:08:30.636
oh, well, that's us working the system or getting away with something, but it's not.
00:08:30.836 --> 00:08:33.856
You just have to make sure you have the accountable or excuse me,
00:08:33.936 --> 00:08:38.696
the records to be able to demonstrate or back up the 340B behind it.
00:08:38.896 --> 00:08:42.036
It's definitely within the rule set my background
00:08:42.036 --> 00:08:44.836
prior to to 340B, I did
00:08:44.836 --> 00:08:47.736
a few years in the revenue cycle and you know it's definitely
00:08:47.736 --> 00:08:52.456
permitted by cms using that ud modifier there's policies out there that are
00:08:52.456 --> 00:08:56.076
publicly available pretty easy to find with a google search look at your top
00:08:56.076 --> 00:08:59.496
payers you know if you're an area that's dominated by a blue you know look up
00:08:59.496 --> 00:09:03.276
that local blue and what's their policy on waste billing and most likely it's
00:09:03.276 --> 00:09:06.356
going to follow what cms says put your medical jws yeah.
00:09:07.133 --> 00:09:11.013
Or JW, thank you for correcting me on there. He was like, that's Medicaid.
00:09:11.193 --> 00:09:14.213
That's wrong. Yeah, I got my modifiers mixed up.
00:09:14.693 --> 00:09:21.293
Yeah, I think that's really important because sometimes the waste is not unavoidable
00:09:21.293 --> 00:09:25.853
because of dosages. So you might as well be doing that documentation.
00:09:25.953 --> 00:09:31.093
But I think that that really brings up a good point that 340B is not a pharmacy program solely.
00:09:31.093 --> 00:09:35.553
It requires working together with your finance team, your billing team,
00:09:35.733 --> 00:09:41.113
your IT and EMR teams, that you really have to get everyone together so you
00:09:41.113 --> 00:09:43.373
can manage that program completely.
00:09:43.373 --> 00:09:46.913
And that goes for the TPA as well, because you have these data feeds.
00:09:47.193 --> 00:09:51.773
And maybe it's a nursing manager that's making sure that those waste codes are
00:09:51.773 --> 00:09:56.853
being put in there correctly. Yeah, I'm a big fan of a well-staffed steering
00:09:56.853 --> 00:09:58.473
committee for the 340B program.
00:09:58.953 --> 00:10:01.833
In one area you missed, too, I think government affairs. I think that's really
00:10:01.833 --> 00:10:05.153
important to have at the table. Like, let's be proactive with this stuff and
00:10:05.153 --> 00:10:06.333
let's not wait till there's a crisis.
00:10:06.993 --> 00:10:09.653
And finance can help with that. Revenue cycle can help with that.
00:10:10.033 --> 00:10:13.793
So I think it's definitely a multidisciplinary approach for a really strong,
00:10:13.933 --> 00:10:16.053
successful 340B IT as well.
00:10:16.213 --> 00:10:20.653
You know, have an IT at the table. So thinking about the entities that may be
00:10:20.653 --> 00:10:23.413
struggling or facing challenges with,
00:10:23.914 --> 00:10:28.054
managing their TPAs or they're not sure if they're making, you know,
00:10:28.154 --> 00:10:31.014
they're keeping up on all the data elements. I'm wondering if we can kind of
00:10:31.014 --> 00:10:35.474
go through two lists, more or less, for people to be able to use as takeaways from this.
00:10:35.614 --> 00:10:42.314
One, I'm thinking, is what elements should they be looking at with their TPAs on a regular basis?
00:10:42.594 --> 00:10:47.214
And then when they're selecting a TPA, what questions should they be asking?
00:10:47.354 --> 00:10:50.534
It's tough when you don't know what you don't know. So what things should you
00:10:50.534 --> 00:10:56.754
go in to that negotiation or conversation, hoping to get out in terms of just
00:10:56.754 --> 00:10:59.654
understanding the program to see if it fits your own covered entity.
00:11:00.354 --> 00:11:04.034
So, I mean, I'll start with, you know, one easy thing that I think could be,
00:11:04.374 --> 00:11:07.174
you know, a starting point of where to dig in a little deeper to try to find
00:11:07.174 --> 00:11:11.214
if there's issues with your program is looking at your accumulator and sorting
00:11:11.214 --> 00:11:14.454
by the negatives and anything that's excessively positive.
00:11:14.494 --> 00:11:18.294
Because if we've got excessive positives, that to me says we've got a multiplier
00:11:18.294 --> 00:11:21.194
issue or we don't have a price in our catalog.
00:11:21.214 --> 00:11:25.154
So every order is getting split to GPO or getting split to WAC and not actually
00:11:25.154 --> 00:11:26.494
being purchased on 340B.
00:11:26.754 --> 00:11:29.634
If it's excessively negative, what happened there, right?
00:11:29.754 --> 00:11:33.094
I had a situation once where a pharmacy tech with very good intentions in one
00:11:33.094 --> 00:11:36.994
of our own pharmacies would go into Cardinal and buy a generic equivalent anytime
00:11:36.994 --> 00:11:38.074
something was out of stock.
00:11:38.474 --> 00:11:40.234
Awesome. I love that you're buying the best price.
00:11:40.793 --> 00:11:44.613
But we don't have the accumulations to back that, right? So you gotta make sure
00:11:44.613 --> 00:11:46.213
that you're focusing on that.
00:11:46.413 --> 00:11:49.793
And then when it comes time for shopping for a vendor
00:11:49.893 --> 00:11:52.753
I would say rely on your peer groups, right?
00:11:52.913 --> 00:11:55.433
Don't just take the sales reps word for it.
00:11:55.773 --> 00:11:58.553
Everyone's gonna say that they're the best, but can they actually prove it?
00:11:59.173 --> 00:12:04.813
So use those conferences again, networking, ask for references from who you're evaluating.
00:12:05.173 --> 00:12:09.713
And I think that all TPAs can build a 340B bucket, right?
00:12:09.713 --> 00:12:15.293
But where areas that I think are distinguishable is the amount of support that
00:12:15.293 --> 00:12:18.553
you're going to get from that TPA because after the contract signed,
00:12:18.813 --> 00:12:20.773
what's the quality of implementation like?
00:12:20.893 --> 00:12:24.513
What is the quality of the support that you're going to get after implementation?
00:12:24.853 --> 00:12:29.333
And a lot of that is publicly tracked by external firms outside of the TPAs.
00:12:29.473 --> 00:12:33.573
So class research is one of them. You can go in, you can look at all the TPAs
00:12:33.573 --> 00:12:35.833
and how they stack up against the competition.
00:12:36.693 --> 00:12:41.853
Cybersecurity is another huge one. You know, I myself got like a $30 check from
00:12:41.853 --> 00:12:44.453
a breach that I was involved with from a hospital back in Pennsylvania.
00:12:44.713 --> 00:12:47.633
And that bought me about a muffin and a Starbucks coffee.
00:12:48.793 --> 00:12:53.213
But I mean, it is a real threat. And, you know, you want to know what is your
00:12:53.213 --> 00:12:55.273
TPA doing to keep your data safe?
00:12:55.293 --> 00:12:58.113
Because the last thing you want to do is be on the front page of a local newspaper
00:12:58.113 --> 00:13:00.893
that there was a data breach from your health center or hospital.
00:13:01.426 --> 00:13:04.806
What kinds of things, like how would they, how would a covered entity know that
00:13:04.806 --> 00:13:10.946
their TPA has proper cybersecurity measures in place? So there is certifications
00:13:10.946 --> 00:13:12.126
out there that are available.
00:13:12.666 --> 00:13:19.786
You know, SOC 2 is one that a lot use. That's more of a financial type of cybersecurity certification.
00:13:20.026 --> 00:13:25.526
And then there's HITRUST, which is the more of the healthcare sector type of cybersecurity.
00:13:25.846 --> 00:13:30.526
And Verity has HITRUST certification. I will say that that is one of the more
00:13:30.526 --> 00:13:34.766
challenging and more expensive certifications to get. So, you know,
00:13:34.866 --> 00:13:38.366
you want to know what kind of security measures are in place.
00:13:38.466 --> 00:13:41.466
And that requires us to have all different kinds of policies and procedures.
00:13:42.266 --> 00:13:44.326
Notifying our customers of any breaches.
00:13:44.686 --> 00:13:48.526
They test our staff regularly. We get phishing attempts all the time and we
00:13:48.526 --> 00:13:51.906
have to submit the phishing report and, you know, get a pass or fail and they
00:13:51.906 --> 00:13:53.006
actually track those rates.
00:13:53.526 --> 00:13:57.166
So, you know, getting to know that and then know what kind of cybersecurity
00:13:57.166 --> 00:13:59.066
coverage that they have, right?
00:13:59.486 --> 00:14:02.506
You know, someone can say, oh, we'll give you unlimited cybersecurity insurance.
00:14:02.506 --> 00:14:05.966
But if you don't have the funds to back it, it's really only as valuable as
00:14:05.966 --> 00:14:08.146
the ink that the paper's printed on.
00:14:08.326 --> 00:14:13.046
So, you know, I think that's a pretty good, what's your service like,
00:14:13.126 --> 00:14:17.086
what's your reputation like, and what's your cybersecurity measures?
00:14:17.086 --> 00:14:22.346
And one of the things I've done and I've talked to other covered entities about
00:14:22.346 --> 00:14:24.306
is you mentioned references,
00:14:24.306 --> 00:14:27.126
but it's also valuable if you find references that
00:14:27.126 --> 00:14:33.086
aren't given by the TPA as well and find them through maybe Nautopod for the
00:14:33.086 --> 00:14:39.866
health centers or the 340B health exchange where you can talk to other people
00:14:39.866 --> 00:14:44.266
and covered entities and get a reference that may not be provided from the vendor
00:14:44.266 --> 00:14:45.806
because you'll get more of a,
00:14:45.866 --> 00:14:48.746
possibly more of a, an honest review of the program.
00:14:49.246 --> 00:14:53.486
And I think something I did that's really simple, doesn't require any Excel
00:14:53.486 --> 00:14:56.086
skills because I have very minimal Excel skills.
00:14:57.126 --> 00:15:01.686
When I was looking through the reports, I would do a simple look each month
00:15:01.686 --> 00:15:04.646
at the tracking of the number of claims captured,
00:15:05.190 --> 00:15:09.110
Because I could easily see if there were anomalies and we would have a month
00:15:09.110 --> 00:15:13.670
where we drop 500 claims at a certain pharmacy and I'd know,
00:15:13.930 --> 00:15:14.870
okay, there's a problem here.
00:15:14.990 --> 00:15:19.530
I don't know what it is, but it clued me in so I could ask the questions.
00:15:19.850 --> 00:15:26.070
And that open communication with the vendor partner is really important.
00:15:26.070 --> 00:15:30.210
You may not need to know what the problem is or how to fix it,
00:15:30.290 --> 00:15:34.710
but knowing who to call and start those conversations. Ghostbusters every time.
00:15:35.190 --> 00:15:41.590
So I agree. And I think another easy way to identify where there may be a problem,
00:15:41.730 --> 00:15:46.630
even if you don't know what's causing it, is periodically pulling your electronic
00:15:46.630 --> 00:15:51.030
prescription report from your medical record to see how many prescriptions are
00:15:51.030 --> 00:15:52.370
going out to each pharmacy.
00:15:52.930 --> 00:15:57.070
And while that won't factor in if you carve out Medicaid or you've got manufacturer
00:15:57.070 --> 00:16:02.710
restrictions there, it will provide you with more or less a comparator for month over month.
00:16:02.850 --> 00:16:07.290
We've been sending about this many prescriptions to this pharmacy and we've
00:16:07.290 --> 00:16:08.670
had about this many qualify.
00:16:08.670 --> 00:16:12.670
And if there's a change that's not reflected in the other number,
00:16:13.270 --> 00:16:16.510
then being able to say, OK, is there something wrong with,
00:16:16.590 --> 00:16:19.390
are we are we qualifying based on prescriber NPI?
00:16:19.790 --> 00:16:23.650
Do we need to update the provider list? Are we qualifying based on location
00:16:23.650 --> 00:16:26.030
ID? Do we need to update any locations?
00:16:26.810 --> 00:16:31.990
Kind of using that as a starting place to be able to dig more for a root cause analysis.
00:16:32.370 --> 00:16:35.330
And most TPAs have a feeds monitor of some sort, right?
00:16:35.450 --> 00:16:38.970
So that's one of my go to's as well. Like if I've got a customer that sent us
00:16:38.970 --> 00:16:44.110
20,000 line items overnight and 900 processed, something's wrong there,
00:16:44.250 --> 00:16:45.270
right? We need to fix that.
00:16:45.510 --> 00:16:49.290
So I would also recommend looking at that, too, and see how many of your files
00:16:49.290 --> 00:16:51.890
are actually processing versus rejecting or duplicating.
00:16:52.870 --> 00:16:55.630
Yeah. Well, thanks so much, Matt. It's been really helpful to go through this.
00:16:55.830 --> 00:16:57.930
It's been fun. Thanks for having me. Yeah, it's been great.
Don’t miss out on critical updates and game-changing strategies. Subscribe to 340Banter today and ensure your FQHC is always a step ahead in 340B compliance.
"340B is not a pharmacy program. It requires working together with your finance, billing, IT, and EMR teams, so you can manage that program completely."
340Banter is brought to you by FQHC 340B Compliance, a trusted partner in optimizing 340B Programs for Federally Qualified Health Centers nationwide. Their mission is to provide tailored resources to help health centers secure and optimize their 340B Programs, improving compliance and oversight. For more information, contact us!
.jpg)
