Academic Medical Center Automates Complex Claims Review Processes

Expanding 340B Eligibility Review to Increase Program Compliance

A large academic medical center (AMC) worked with Huron to develop and implement a customized automation solution to expand the eligibility review of 340B claims and improve accuracy, which increased compliance and freed up staff to work on more strategic tasks.

Challenge

As a provider in the federal 340B Drug Pricing Program, the AMC was tasked with increasing program compliance for more than 200,000 medication dispenses per month across its hospital, retail and contract sites.

Despite a robust 340B auditing team, the organization’s complexity and software constraints allowed for only approximately 200 reviews per month. These limitations resulted in missed eligibility and the inability to verify 100% program compliance.

AMC leadership sought a sustainable, technology-based solution that would scale its auditing capabilities to expand the eligibility review of 340B program claims and free up staff for more strategic work and compliance tasks not suitable for automation.

Approach

Given the complexity of the healthcare environment and 340B program, the health system needed a technology solution that could be customized to navigate the unique and complex aspects of its work. Together, Huron and the AMC developed a custom robotic process automation (RPA) program to seamlessly audit 250,000 claims per month. The program focused on:

Implementing customized automation: Leveraging RPA software, Huron collaborated with the organization’s 340B team and internal developers to build and implement automation that could comb through 340B claims to verify eligibility and find eligible claims that had been missed. Since the auditing process can vary per claim, building the RPA program required a deep understanding of 340B to critically think through program requirements and the AMC’s health information systems and data verification process. To ensure successful integration, automations were tailored to support the team’s audit workflows and 340B program road map. During this process, Huron was also able to help restructure and further improve the organization’s overall auditing process.

Expanding the program and improving oversight management without significant costs: Manual auditing tasks, such as drug code verification and visit eligibility review, were automated, speeding up the auditing process and freeing up staff to focus on more value-added work. Automation enabled the 340B team to maximize eligibility review from 200 claims per month to 250,000 claims, saving more than 200,000 hours of manual auditing, which would have required an additional 120 full-time employees. This approach provided the organization with a cost-effective solution to scale auditing capacity in the future.

Increasing program compliance: By expanding the eligibility review of 340B claims, the AMC has been able to significantly increase program compliance, minimizing the risk of manufacturer paybacks. Automation was programmed to identify claims that the third-party pharmacy administrator (TPA) system inaccurately deemed ineligible, increasing the number of eligible claims. The automated review process also reduced the number of claims misidentified as eligible, allowing the organization to make the correction before a drug is replenished.

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