A university health system, headquartered in the U.S. Northeast, is a multi-hospital and home health system with thousands of physicians, nurses, and other clinicians. National media ranked the health network’s medical center among the nation’s best. In 2016, the health network launched its 340B program. The manager of the 340B program directs a team of six analysts who run the program for the hospitals in the health network.
“Our job is keeping this program in compliance,” says the 340B program manager. “Before automating the way we monitor and identify our trouble spots, we did it all manually.”
Engaging in hand-to-hand compliance
According to the manager, her team would perform a manual check of the health network’s records and contracts related to the Office of Pharmacy Affairs Information System each quarter or two. The manual approach, says the manager, opened the possibility of a compliance risk. Tracking and reviewing records by hand to keep tabs on the status of her program’s agreements with contract pharmacies posed another challenge. If, for instance, her team completed a review at the beginning of the quarter and then received notice for a U.S. Health Resources & Services Administration audit in mid-February, she says the team would require at least one person or more spending hours outside normal hours vetting contract agreements, signatures, and more.
Automatic help for auditing and reviewing 340B program eligibility
In 2019, the health system’s 340B program manager called on software provider Sectyr® to implement its software-as-a-service SectyrHub® 340B compliance software. The goal was to automate the auditing and review of eligibility requirements for the 340B program. For the university health network, SectyrHub creates one location for all the information an HRSA auditor would request.
For the 340B program team, SectyrHub’s logic-based, 340B-specific workflows ensure the group is meeting eligibility requirements by prompting them to review critical documents and details. For example, the software alerts the team to look at:
- the Disproportionate Share Hospital percentages for DSH entities in the Medicare cost report,
- pharmacy services agreements, and
- OPAIS changes, and more.
The manager says the solution also prevents the diversion of 340B drugs to ineligible patients by allowing her team to easily tap into the system and audit discounts. Within the software’s “Document Repository,” analysts can see if prescriptions were filled only for patients meeting the program’s requirements.
To keep an eye on duplicate discounts, she says, “The solution has a functionality that allows us to review the Medicaid Exclusion File used by states in the duplicate discounts prevention effort.”
Audit readiness every day
“There’s no way to perform these compliance checks manually each day, and no way as a covered entity to set up a daily feed with the OPAIS even if we invested elsewhere,” notes the 340B program manager. “Sectyr has thought through the details.”
The health system has worked with a 340B program consultant for years, relying on the consultancy for guidance on its 340B program. The health system’s 340B program manager believes what Sectyr provides is complementary to her 340B consultants. She makes the point by noting how synchronizing daily with the OPAIS “has been huge” because a consultancy wouldn’t take on work like this, and, in the past, her team would manually review up to 70 of these contracts each quarter.
“Looking at these contracts, one after another, your eyes start to get blurry,” adds the manager. “But SectyrHub automatically alerts us to what HRSA would look for, and we can act on it because the system sends reminders for edits, renewals, whatever.”
SectyrHub organizes the health network’s 340B program through a central dashboard with tiles mirroring the health system’s covered entities. In the software, for instance, a Disproportionate Share Hospital will have a tile leading to all the documents associated with its operations. From there, staff can dive into, say, a Medicare cost report. Other documents might include a cover page with a signature box. If necessary, SectyrHub prompts users to sign off when entering the information, so there’s a record for the 340B program team. When the health system files a cost report, Sectyr prompts a user to review the report. “SectyrHub is critical for maintaining that DSH percentage and keeping an eye on it,” says the manager. “We also use SectyrHub to teach new analysts about the elements of our 340B program. When I introduce new analysts to our work instead of saying, ‘Here’s what a contract looks like,’ they can log into SectyrHub and see a pharmacy services agreement or Medicare cost report in the context of their job.”