CMS Releases Final OPPS Rates for 340B Covered Entities

  • 0
Centers_for_Medicare_and_Medicaid_Services_logo

 CMS Releases Final OPPS Rates for 340B Covered Entities

On November 1, CMS released their final rule implementing Part B payment reductions for Disproportionate Share Hospitals (DSH) as well as Rural Referral Centers (RRC).  The Final Rule, which will begin January 1st 2018, will reduce payment for most separately reimbursed Part B drugs from a current average sales price (ASP) + 6% to ASP – 22.5%.  Under the proposed changes, if a drug’s ASP cost is $50,000, CMS currently pays $53,000, but starting January 1st, CMS will pay $38,750 for the same drug. Payment for vaccines will not change.  The estimated savings to CMS is believed to be around $1.65 billion, nearly double from the original estimate of $900 million. The savings will be re-allocated to other OPPS services.

Read More

  • 0
indirect referrals

Mitigating Risks of Indirect Referrals

Sometimes, reliance on a referral request to an outside prescriber (e.g., specialist) to qualify a prescription as 340B eligible can be relatively straightforward. For instance, when a direct referral request to the actual prescriber is documented in the patient’s medical record along with a referral visit summary back closing the loop, the covered entity’s responsibility of care can be clearly demonstrated.

Read More

  • 0
stayontarget_340B

Chief Cook and Bottle Washer: Self-Auditing For 340B, When You Are the ‘Whole Enchilada’

Let’s be honest, pharmacy is not for the faint of heart. Add to regular pharmacy duties the immense joy of the 340B program and you can be over your head…quickly. 340B self-auditing can feel like a pipe dream. HRSA auditors may haunt your nightmares, with Zombies, that have an uncanny resemblance to your CFO and Compliance Manager, waving a Medicaid Cost Report…(ahem), I digress.
340B is a complex program that requires hands on, good old-fashioned work. Even with fancy, schmancy 340B software, the covered entity is ultimately responsible for compliance. Therefore, self-auditing should be one of your top priorities.

Read More

  • 0
IMG_3541

340B Summer ’17 Coalition Meeting

We had a great time in DC for the 340B Coalition Meeting. Thank you to everyone who stopped by the booth to say hello, or to learn more about our services. We thought the conference did well with keeping the 340B community updated on what is potentially coming with 340B changes, of course, it is still speculation in most cases. Rich Bucher and Rob Nahoopii will try to hit the highlights below.
Ted Slafsky, President and CEO of 340B Health, spoke about the state of 340B, and looking back and moving forward. Ted noted recent scrutiny of disproportionate share hospitals (DSHs) and pointed out that while 36% of this nation’s hospitals are DSHs, they provide close to 60% of this nation’s uncompensated care. He also pointed out that many rural hospitals would most likely have to shut their doors if not for the 340B program. For perspective, it was also noted that manufacturers spend four times as much on advertising as they do on the 340B program.

Read More

  • 0
340b_aca_turnkey

340B, the ACA, and YOU

To fully address the topic of how 340B and the ACA are intertwined would take far more than one blarticle (Roxie word for blog + article); but I will do my best to “nutshell” it. Regardless of your political views and where you stand on the “Repeal and Replace” agenda regarding the Affordable Care Act, if it is repealed and replaced this could be huge (YUUUGE), and even detrimental for and to your 340B program in one, two, or both ways. When the ACA was signed into place in 2010 (yeah, it’s been that long ago!), it expanded the types of sites that could be considered “covered entities” such as children’s hospitals, free-standing cancer hospitals, rural referral centers, critical access hospitals, and sole community hospitals. My guess is that more than a few of you fall into one of these types of covered entities whose 340B programs could go out the window faster than Trump can say, “you’re fired.” (Remember when he was just a fun celebrity personality with a catch phrase?!)

Read More

  • 0
dreamstimelarge_5929053

Contract Pharmacy – Is it a Risk You Are Willing To Take?

When you think of compliance pitfalls in the 340B Program, contract pharmacy immediately comes to mind. Contract pharmacy is one of the highest compliance risk areas of the 340B program; however, the reward of better serving our vulnerable and underserved patients to many is well worth the risk. Contract pharmacies have allowed covered entities to expand their reach to the most vulnerable of patients. Through 340B savings, many covered entities have provided: access to medications, support for non-covered procedures; improved healthcare and education; and support and resources for patient care. In many cases, these most vulnerable patients would have otherwise fallen through the cracks of our sometimes-flawed healthcare system. So how does the covered entity handle the complexities of the contract pharmacy arrangements?

Read More

  • 0
Health care reform concept with a RX pharmacy medical symbol in a puzzle jigsaw texture with peices missing as change to the status quo of the broken hospital care insurance and healthcare system that needs to be fixed.

A Review of Expectations to Prevent Duplicate Discount

Carve-In Medicaid Entities:

At a minimum, list the NPI of the entity for each registered site on the HRSA database and subsequently the Medicaid exclusion file (MEF).  Covered entities (CEs) with multiple child sites will need to confirm the NPI number used for billing at each site as it might be different than the parent NPI.  In addition, Medicaid provider numbers (MPNs) for each site should also be listed, as suggested by a recent 340B Health Webinar on HRSA audit findings.  It is not clearly explained by HRSA if the NPI or MPN is preferred, therefore best practice is to place both numbers on the MEF.  Confirmation that the information is correct on the MEF should be reviewed quarterly and annually during recertification.

During a recent HRSA audit, the auditor asked that for each FFS claim sampled, the CE demonstrate that the NPI placed on the claim/UB04 matched the NPI listed on the database.  The auditor also asked that confirmation of discussion of the carve-in arrangement that occurred with the State DHS office be uploaded as data by the end of the audit.

Read More

  • 0
340B conference

340B Update: Omnibus Withdrawal & 340B Coalition Conference

Well, big news out yesterday. As of 1/30/2017, the 340B Omnibus Guidance is officially withdrawn.

Where does that leave us?

Well, that brings be to my second topic, the 340B Winter Coalition Conference. I am in my seat on our airplane to San Francisco. I am excited for this conference, as the legislative sessions will be very hot topics. We, Turnkey, are taking 7 staff to the conference, and have our booth (come visit us at booth 57 if you are attending). In the event you are not attending, we will share some of the follow-up to what the discussion is around the post-Omnibus withdrawal 340B landscape. My personal thought is that HRSA may be waiting for rule making authority to formally write more specific rules and guidance on the 340B program. Especially around the 340B patient definition. Of course, this would require legislation, which is why I am excited to hear from 340B Health about all the bills in the senate and house. We also have to worry about the current ACA repeal potential and how that might affect our ACA covered entities (i.e., CAH, RRC, SCH, and CAN). Stay tuned my friends!

Read More

  • 0
gpo_drugs

Are you ready for a mock audit with Turnkey?

For those who have had an audit from Turnkey, you already know how important it is to have a strategy in place for every drug in every location that ensures 340B compliance. At the very least, this should include ensuring that patient-specific and drug-specific auditable records are maintained and available, that 340B drugs are only qualified for 340B eligible patients, and that duplicate discount violations are prevented.

Furthermore, if you are a disproportionate share hospital (DSH), children’s hospital, or freestanding cancer hospital subject to the GPO prohibition (GPO affected entity), you’d better also have a strategy in place for every such drug and location that ensures against possible GPO prohibition violations.

Read More

  • 0
medicaid_claims_mco

Split billing company, suggestion on Medicaid Claims for Contract Pharmacy? Consider this

When your split billing company suggests it is Ok to include Managed Care Medicaid claims for contract pharmacy, please consider the following:

Allowing managed (MCO) Medicaid 340B accumulations, for contract pharmacy, is not worth the risk because at the end of the day it would likely be the covered entity that would have to work out the impact with the manufacturer (and potentially HRSA if it were Material).

Apexus sticks to its advice that,

340B drugs should not be used in a contract pharmacy situation for Medicaid patients unless there is an arrangement to prevent duplicate discounts that has been reported to HRSA in collaboration with the state Medicaid agency” – note they do not make special exception or have different advice for MCO claims.

Read More