Millions of patients have been touched nationwide by our client’s services, uniting patients with community pharmacies. Our client’s innovative and industry-standard setting technology supports the safety net mission by engaging its contracted pharmacy network-based delivery of Public Health Service 340B, GPO, and PAP drugs.
Our client operates the nation’s best 340B contracted pharmacy network, bringing savings to patients per the 340B Drug Program mission. They are a pioneering technology leader in 340B processing and automation through their proprietary system leveraging, web-based technologies.
Our client wanted to enter the Medicaid market for the reclassification of 340B claims. They enlisted Y&L to create an application that helped them achieve the following goals.
- Create and support a simple process for MCOs, pharmacies, and 340B administrators to submit data files for the identification of 340B claims.
- Create and support a scalable, comprehensive, and robust solution for MCOs to demonstrate to the State an effective 340B compliance and performance program across both retail and specialty pharmacy patients.
- Identify and report to the State all Medicaid claims in which the ingredient cost was purchased with 340B discounted prices.
- Create a solution to share 340B data, savings, performance, and refunds with ease using agreed-upon standards.
- Prepare shared savings invoices and reports and settle funds collection and payments.
At a high level, Y&L created a solution that contained multiple integrations/interfaces, a flexible and scalable audit rules engine, and multiple web-based portals.
Following are the core development activities that took place:
- Develop an audit/matching engine to support the solution for Managed Care Providers (MCO) to identify and report 340B claims:
- Where savings can be achieved and state rebate position maintained, produce and transmit the 340B state file, reverse managed Medicaid claims and reclassify them as 340B.
- Determine shared savings between the state, MCO, and other entities, and settle funds.
- Develop specifications and approach for receiving claims from the entities; provide feedback to the entities of approvals that “pass” or “fail”.
- Develop three web-based portals:
- MCO portal to view claims and invoices and produce reports
- Entity portal to view claims and invoices and produce reports
- Client 340B administrative tool to establish state specific and MCO specific rules; set up to also allow for multiple client 340B reimbursement models.
Critical Success Factors:
The following are the success factors that guided our development activities:
- Scalable Solution – We expected a monthly claim volume of 100+ million
- HIPPA Compliance – We needed safeguards for handling and data transmission
- Claims Management – We needed a solution for handling single and multi-payer claims and identifying distinct claims between the MCO and Entity in order to calculate savings. It also needed to have a robust claims reversal process.
- Governance – We needed the ability to track claims from source data to invoicing rejection. In addition, it needed to allow the MCO/Entity to track the status of data submission and individual claims without engaging internal client resources.
- Client successfully entered/created a new market space through programmatic innovation, which will deliver significant revenue to themselves, MCOs, and other entities.
- Project was scoped and performed entirely by Y&L. Y&L was responsible for the overall software development lifecycle.
- Y&L engaged 15 onsite/offshore resources to deliver this solution.
- Our scalable solution met the client’s expected demand. The flexible application design allows for further scaling by adding hardware.
- Y&L will be performing application maintenance services (AMS) to support/ enhance the solution over the next 6 to 12 months.