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

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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.
However, as chief cook and bottle washer you may not have said fancy schmancy 340B software or, more importantly, time. When you are the ‘Whole Enchilada’ for your site, time is precious. Self-auditing is the key for discovering issues within your entity and will always take you one step ahead of the game. Below are 3 quick ideas to add to your self-auditing process to get the most bang for your buck in your limited time.

  1. Targeted samples

    Using targets in your sampling process, allows you to make the most use of your time. Look for outliers with specific intent, releasing you the burden of drudging through random samples hoping to find something. Targets work best with self-auditing because you know your program. You know what the issues are and what to look for. Targets may include looking for ineligible locations, ineligible patients, ineligible providers, and ineligible payors. If you are carve-out, this is imperative. Create a list of all Medicaid and MCO claims for your state, and for other applicable states, then learn to recognize those in your samples. Identifying issues early, will save hours of work later.

  2. Target high cost drugs

    HRSA auditors target high cost drugs. These could include drugs in aggregate, such as IV solutions or high cost oncology drugs. Checking pack size multiplier (e.g., BUPP for Macro Helix) and accumulations as well as targeting them in patient samples will ensure a mitigated risk later.

  3. Target low volume areas

    These can include locations within your entity as well as child sites, and providers. Easy…Can you find a provider that only has one claim? Could be ineligible. Can you find a claim from a location in your entity that should not be dispensing drugs? Could be ineligible. Know of areas that have had problems in the past? Target. Pivot tables are our friends.
    Completing several samples, a day or week will make it much easier than trying to find large chunks of time at the end of the month. 15 min a day or 30 min a week over the month will add up to a compliant 340B program. As Red Leader in Star Wars so eloquently stated…”Stay on Target, Stay on Target”. Follow these tips and you will be sleeping like a baby in no time.

About Author

Jen Cook

Experience as a pharmacy technician specializing in hospital pharmacy. Jen’s background includes front line healthcare, pharmacy database management, as well as 340B corporate compliance within a 22 hospital system. Jen loves that her work makes an impact on communities, organizations, and families. Jen is part of our independent 340B auditing team and provides data expertise. Her perspective is compliance and data management.

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