The 340B Drug Pricing Program and the related Prime Vendor Program, or PVP, provides discounts on the purchase of outpatient drugs to certain providers.
For many nonprofit and rural providers, the 340B program is a lifeline, providing drugs that are often given out to patients that can’t afford to pay their bill.
It appears that Medicare’s big concern is that participating providers may benefit by buying the drugs at a discount, then benefit again when the drugs that are separately billable are paid by Medicare for Medicare patients.
Here is a guide to which types of hospitals qualify for 340B:
Back in January 2018, Medicare slashed payments for certain drugs under the 340B program. Medicare specifically cut payments for “separately billable” drugs, from 6 percent over the standard average sales price (SASP) to 22.5 percent less than the SASP.
The American Hospital Association (AHA) filed suit, and surprisingly won a rate-setting battle when a district court ruled that Medicare had exceeded its authority and made the cuts without underlying data to support the computation.
On July 31, the District of Columbia Circuit Court of Appeals overturned the lower court ruling, allowing the cut from 2018 to stand.
In the proposed rule for 2021, Medicare is driving the knife in deeper by further reducing the payment, from SASP minus 22.5 percent to SASP minus 28.7 percent.
It is not clear whether or not the Centers for Medicare & Medicaid Services (CMS) is wringing out the profit on these “separately payable” drugs or creating a situation in which providers are losing money when they provide these drugs. It does seem that part of the move may be designed to punish hospitals for disputing rate cuts by making further cuts.
Programming Note: Maureen Testoni, CEO for 340B Health, will be the special guest on Monitor Mondays, Monday, Aug. 24, 10-10:30 a.m. EST. Register to listen.
Is the membership of PHARMA.org made up almost exclusively by companies that sell high priced drugs and devices? Unless you live under a rock, you
The Supreme Court ruling strikes down Medicare payment cuts. On June 15, the U.S. Supreme Court sided with hospital groups in a case challenging the 340B payment
Please log in to your account to comment on this article.
Dr. Ronald Hirsch provides tried-and-true strategies and insight into outpatient in hospital bed stays including determining the applicable definition, who uses it, and when and how to bill for this circumstance, solidified with concrete case examples and expert insight.
Practical solutions for CDM departments to protect your hospital’s revenue.
This webcast teaches hospitals how to comply with CMS price transparency rules and compare their rates with peer hospitals. It covers creating a compliant machine-readable file, comparing negotiated rates, and improving pricing decisions.
The No Surprises Act (NSA) presents a challenge for hospitals and providers who must provide Good Faith Estimates (GFEs) for all schedulable services for self-pay and uninsured patients. Compliance is necessary, but few hospitals have been able to fully comply with the requirements despite being a year into the NSA. This webcast provides an overview of the NSA/GFE policy, its impact, and a step-by-step process to adhere to the requirements and avoid non-compliance penalties.
This expert-guided webcast will showcase tips for providers to ensure appropriate capture of the work performed for a visit. Comprehensive examples will be given that demonstrate documentation gaps and how to educate providers on the documentation necessary to appropriately assign a level of service. You will gain clarification on answers regarding emergency department and urgent care coding circumstances as well as a review of how/when it is appropriate to code for E&M in radiology and more.
Set yourself up for financial and compliance success with expert guidance that breaks down the impactful changes including MS-DRG methodology, surgical hierarchy updates, and many new technology add-on payments (NTAPs). Identify areas of potential challenge ahead of time and master solutions for all 2024 Proposed IPPS changes.
Do you struggle with selecting and appending the correct modifier for your medical claims? Join our must-attend webinar, “Mastering Modifier Usage: Preventing Denials and Ensuring Compliance” to reduce claim denials and improve your reimbursement rates.
Kay Piper reviews the guidance and updates coders and CDISs on important information in the AHA’s fourth quarter 2023 ICD-10-CM/PCS Quarterly Coding Clinic in an easy to access on-demand webcast.
Copyright © 2023 ICD10monitor. Powered by MedLearn Media.
