03/04/2019

Priority Health

News Updates

Many thanks to MSHO Managed Care Committee Member Robin Frey for sharing these important updates with our members.

Robin Frey, CPC, CHONC
Reimbursement Manager 
Cancer & Hematology Centers of Western Michigan, PC

Modifier required for 340b payable drugs, recoupment upcoming for 2018 claims

Effective Jan. 1, 2018, Medicare began to reimburse payable drugs and biological agents purchased through the 340b program at an adjusted amount for those hospitals paid under the Hospital Outpatient Prospective Payment System (OPPS). The 340b program gives drug subsidies to pre-qualified providers through the Health Services and Resources Administration (HRSA) of the federal government. Because these drugs and biologicals are obtained at a subsidized rate, they must be billed with the JG and TB modifiers.

As of January 19, 2019, Priority Health will deny any claims billed by a 340b eligible facility for these payable drugs and biological agents billed without the proper modifiers. In addition, we will begin recouping payment for any claim paid in 2018 that was not billed with the proper modifier. Providers are encouraged to rebill any recouped claims with the proper modifiers.

Patients will not be directly impacted, other than potentially receiving additional EOBs as claims are recouped and reprocessed.