In our last post, we focused on HRSA’s 2015 agenda item to complete at least 200 340B audits and listed several risk factors that could increase the likelihood of a 340B entity being selected for an audit. There is no way to be certain if an audit for your 340B entity is on the horizon, but here are some things you may want to do to get your facility ready, just to be on the safe side. Que The Temptations’ “Get Ready” in the background...
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Make good friends with those people down in credentialing and those wonderful people who work on your facility’s cost report. It’s probably time you bought them breakfast if you haven’t already. Make some time to talk to them about the parts of the cost report that affect your 340B status (worksheets A, E, S2, S, C). You want to know what your cost report looks like ahead of time before you present it to HRSA, what your DSH percentage is (if you have one), where your clinics and child sites are in the trial balance, and just be familiar with the documents and where everything is in it. Also, talk to credentialing about setting up some sort of timely notification for when physicians find employment elsewhere and when your facility has hired on or contracted new physicians, so that you are accurately keeping up with your physicians list and you aren’t under or over qualifying.
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For those of you with Contract Pharmacies: Find your contracts or your pharmacy service agreements. There are quite a few covered entities out there that don’t know where the contracts are that they signed with their contract pharmacies, and even when they do find them, they aren’t completely signed. This is bad. Before HRSA shows up at your front door (we all know they don’t come around back), make sure that these documents are where you can get to them and that they are complete.
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Your policies and procedures are a key item when it comes to an audit and if you have to struggle to produce this piece for HRSA, things will not go well for you. Please do not pull down the draft template from the Apexus website and give HRSA that. A lot of entities will use the template their 340B software vendor provides them, however, if you decide to use that as a jumping off point, please remember to remove the [entity] and put your facility’s name in there. Remember though, this is YOUR program. You are in the driver’s seat and it is up to you to take charge and decide how you want to run it. The templates from Apexus and the software vendors are just guides to give you direction. Sure, there are certain items from those templates that you will want to address in your own policies and procedures, but this is your chance to say “this is how we do things around here”. This is your facility and your program. You need to own it. HRSA just wants to see you administer it accurately and with the utmost compliance.
Something to remember is that we are all trying to work through this together. Everyone is doing their best to try to get it right and to make this program work because it is a great program. It’s not an easy road, but it is one worth traveling because the destination is stretched resources and savings that will essentially be used to help more patients. And that’s really the ultimate goal. So here’s to getting it right.
READ MORE ON THE 340B DRUG DISCOUNT PROGRAM AND SCA's 340B AUDIT & COMPLIANCE SERVICES...
