fbpx

< Back to Thought Leadership

New Requirements by Anthem for 340B Participants

Attention 340B covered entities participating with Anthem Blue Cross and Blue Shield: Effective April 1, 2019, Anthem requires that a “JG,” “TB,” or another relevant modifier be added to claims involving 340B eligible outpatient drugs under the Medicare Outpatient Prospective Payment System (OPPS).

This decision by Anthem resembles the January 1, 2018 decision by the Centers for Medicare and Medicaid Services (CMS) to reduce the Medicare Part B allowed reimbursement rate for 340B drugs from ASP plus 6 percent to ASP minus 22.5 percent. CMS simultaneously increased the conversion factor for all OPPS non-drug items and services by approximately 3.2%.

It may be prudent to reach out to Anthem for clarity on this issue. A recent federal court ruling in Washington reversed the enormous cuts to the Medicare outpatient drug payments implemented by CMS. A federal judge ruled in late December 2018 that CMS and HHS exceeded their authority by cutting 340B reimbursement by approximately 28.5%. While this ruling appears to be a win for the hospitals affected by the payments cuts, it is not certain how this issue will be settled. Additionally, there has been no guidance by Anthem as to how this ruling affects their position.

Anthem advises that these facilities are excluded from this billing requirement:

  • Sole Community Hospitals (SCHs)
  • Children’s Hospitals
  • PPO-Exempt Cancer Hospitals
  • Critical Access Hospitals (CAHs)
  • Drugs administered or dispensed in non-excepted Hospital off-campus outpatient departments (HOPDs)

Blue & Co. will continue to monitor the situation and update clients as more information becomes available. If you have any questions, please contact one of our 340B Apexus Certified Experts:

Jason Prokopik, Pharmacy Manager
jprokopik@blueandco.com
317-713-7916

 

woman using a quickbooks point of sale system

Blue & Co. Offers Expertise to Not-For-Profits Affected by QuickBooks Point of Sale Discontinuation

By Nancy Orben, CPA, Senior Manager, Laura Philpot, Senior Accountant, Business Services, and Lisa Totten, Senior Accounting Specialist at Blue & Co. Attention all not-for-profit organizations! Are you currently using QuickBooks Point of Sale in your gift shops, ticket sales, or day-to-day business? If so, you may have heard the recent news that Intuit will […]

Learn More

Contract Services: Impact on Wage Index

In the past several years, hospitals have continued to feel the impact of increased utilization of contract nursing and other contract services. Although these services have developed into a major expense line item, it is important for hospitals understand how expenses related to contracted services can impact the wage index factor for Medicare reimbursement. Contract […]

Learn More
shamrocks not-for-profit tips

3 Lucky Tips for Not-For-Profits to Avoid Bank Fraud

Trusted Insights from The National Bank of Indianapolis Nonprofit Services Team Not-for-profit organizations are increasingly falling victim to fraud, with a rising number of incidents and an ever-growing amount of money being lost. Fraudsters find it easy to target not-for-profits, as their publicly available 990s provide valuable information. Protecting your organization from such fraudulent activities […]

Learn More