Challenge
Choctaw Regional Medical Center is a fifteen-bed Critical Access Hospital (CAH) in Ackerman, Mississippi that serves 38,000 to 40,000 patients annually and has one retail contract pharmacy and 11 specialty contract pharmacies. Choctaw wanted a way to optimize its 340B strategy for chronic care patients and improve continuity of care by “closing the loop” on referrals made to specialty partners. In addition, Choctaw specifically wanted to capture referral prescriptions from its large retail contract pharmacies.
Choctaw Regional Medical Center also needed to ensure that any referral prescription claims were compliant with 340B program guidelines. For referral-based scripts, this means obtaining consultation notes from the specialist and reviewing them for various compliance checkpoints, such as whether the encounter notes include mention of relevant prescriptions. This places a significant burden on covered entities (CEs) which — for CAHs and other rural-area program participants — already face unique challenges based on geography and patient population.
Solution
When Choctaw learned about R1 340B Recovery, they immediately requested a meeting and demonstration. R1 340B Recovery is a compliance-first, technology-enabled solution that reverses ineligible contract pharmacy claims into recovered 340B savings by finding missing prescriptions written by eligible and referred-to providers. After learning more about the solution and finding out that its large retail pharmacy had partnered exclusively with R1 for referral prescription claims, Choctaw decided to partner with R1 and became one of its first ten CE clients in July 2018.
Results
Choctaw has been able to capture an additional 1,300 claims for 340B pricing due to its partnership with R1, which accounts for 5% to 7% of its overall 340B program revenue. Of those 1,300 claims, the referral prescriptions were primarily written by cardiologists, neurologists or endocrinologists, the most common of which were for Eliquis, Xarelto and Vimpat.
R1 340B Recovery helps TPAs identify the referring organization of a script that was delivered to the pharmacy outside of the EHR, such as via phone or fax. Because R1’s audit-first technology solution can unify referral and EHR encounter data, providers like Choctaw can rapidly identify and recover contract pharmacy claims that are needles in the haystack and ensure those savings are justified. In fact, in 2020, Choctaw was selected for an HRSA audit. Because their Policies & Procedures were well defined and carefully articulated, it passed the audit with zero findings — a validation of compliance standards enforced by R1 and put in place by Choctaw’s policies and procedures.
