On September 28, 2022 the US District Court issued a ruling that states the Department of Health and Human Services (HHS) is required to vacate the prospective portion of the 340B reimbursement rate outlined in the 2022 Outpatient Prospective Payment System (OPPS) Rule. In other words, payment rates must revert to the default of ASP + 6% rather than the reduced rate for select drugs of ASP – 22.5%. The decision was determined to not cause substantial disruption; thereby, requiring HHS to begin immediately. This was in response to American Hospital Association v. Becerra, 142 S. Ct. 1896 (2022), in which the Supreme Court ruled against the Department of Health and Human Services (HHS) stating they exceeded their statutory authority by varying its 2018 and 2019 OPPS reimbursement rates for 340B hospitals without first conducting a statutorily mandated survey of hospitals acquisition costs.
CMS has issued a statement that they will be reprocessing claims contractors paid on or after September 28, 2022 using the default rate of ASP+6%. CMS is also uploading a revised OPPS drug file that will apply the default rate generally ASP+6% to the 340B drugs the remainder of this year. Additionally, providers can contact their MAC to make a mass adjustment for claims paid prior to September 28, 2022.
- Revenue integrity teams should be aware that Medicare fee-for-service claims paid at the ASP – 22.5% will be reprocessed and paid at generally ASP+6%. This is effective for claims paid on or after September 28, 2022.
- Revenue integrity teams should contact their MAC to determine the process for making a mass adjustment to claims paid prior to September 28, 2022.
- Pharmacy and finance teams should review the impact to the price change and the associated impact to pharmacy budgets.
- Revenue cycle teams should be on the lookout for upcoming discussions and changes to the OPPS CY 2023.
Our goal is simple; we’re taking complex information and making it practical. Until our next edition, this is Maxie Friemel and Agatha Nolen providing you with tips for increasing your Pharmacy Revenue.