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In this series of articles, we highlight cases in which Apexus Answers, a resource provided by the 340B Prime Vendor Program, was a valuable resource for 340B stakeholders who contacted the call center. Read Part I of this series here.
Continuing our look into how you can use the Apexus Answers call center to support your program compliance, we will highlight a few more cases that show examples of interventions made through those interactions. As a reminder, you can contact the Apexus Answers call center via phone, live webchat, or email for all of your 340B Program questions. The call center operates as part of our agreement with HRSA as the 340B Prime Vendor.
A New York DSH facility had been conducting its regular self-audit and found a possible duplicate discount. Because the entity had never come across a possible duplicate discount before, it decided to call Apexus Answers to understand what its next steps should be.
Resolution: The call center started the conversation by confirming that this DSH facility was on the OPAIS Medicaid Exclusion File as carving in for Medicaid fee for service, and that it was set up to include UD modifiers on its claims to the state according to New York’s billing requirements for both fee for service and managed care organization claims. However, because a UD modifier had been left off one of its claims, the call center specialist then focused on how the covered entity could gather information from the state Medicaid office. This is critical in order to validate if a rebate had been sought to determine if a duplicate discount did occur on that claim.
Outcome: The specialist looked up and provided the covered entity with the specific New York state Medicaid contact. The specialist also advised that the DSH contact could call the manufacturer as well to verify that no rebate had been sought, confirming that no duplicate discount had occurred. If a rebate was sought, the hospital member was provided information on how to work with the manufacturer to resolve the issue. This member was very grateful for the guidance, contact information, and the next steps provided by our call center specialist. The Apexus Answers call center maintains contact information and resources to determine state billing requirements, which makes working with state Medicaid agencies easier!
A 340B manager contacted Apexus Answers with a question regarding how its retail pharmacy can carve out Medicaid and its DSH can continue carving in. The entity wanted to ensure that the state Medicaid office would know that the retail pharmacy was carving out.
Resolution: The call center specialist confirmed that the retail pharmacy and the hospital pharmacy had different NPI (National Provider Identifier) numbers, supporting the ability to make different carve-in decisions. The Apexus Answers call center directed the covered entity to its specific state Medicaid billing requirement information. The specialist was able to confirm that the state being billed does in fact use the Medicaid Exclusion File (MEF) as the sole source to determine which providers are carved in. The call center specialist informed the 340B manager that if the retail pharmacy did not list its NPI number in the Medicaid Exclusion File on the 340B OPAIS, then HRSA and the state Medicaid agency being billed would use the MEF to identify that NPI as a carve-out. The specialist also informed the entity that it would need to contact any state Medicaid agency being billed to determine what the state’s billing requirements are and how 340B claims are identified in that state. The call center was able to provide the covered entity with the questions to ask each state agency to ensure compliance for the retail and the DSH pharmacies. The specialist also directed the covered entity to the specific HRSA webpage for additional information on this topic.
Outcome: Because the carved-in DSH entity had a separate NPI number from that of the retail pharmacy, and the retail pharmacy is not listing its NPI number on the MEF, that covered entity would be compliant with purchasing non-340B drugs for its Medicaid patients at the retail pharmacy. Meanwhile, the DSH hospital can continue to purchase all other (non-retail) outpatient Medicaid medications at the 340B price because the DSH entity had listed its NPI number on the MEF file on 340B OPAIS.
Stay tuned for the next article in this series on call center interventions!
Watch 340B OnDemand Module 1, “Introduction to the 340B Drug Pricing Program,” and get the basics in less than 15 minutes.