Problem: Getting the Right Modifiers on the Claims

As of January 1, 2024, the Centers for Medicare & Medicaid Services (CMS) requires entities to report whether a 340B priced product was used in Part B outpatient claims. This presents a challenge as most entities use a virtual inventory system for 340B products administered by third parties (340B TPA’s).

Despite this, Creating an automated or semi-automated rule to maintain compliance with 340B and Medicare Part B is totally possible.

What is a “Claims Scrubber” Technology?

A claims scrubber acts as an intermediary between Electronic Health Record (EHR) systems and payers. It reviews claims generated by clinicians’ services, determining if a claim is clean or requires editing or holding based on specific rules. This technology is crucial for ensuring that claims are compliant and accurately reflect the services provided.

How to use a Claim Scrubber Rule to solve this problem

We can bridge this gap by utilizing the claims scrubber rule features. We propose two distinct workflows to address the 340B modifier requirement: a universal rule build and a patient-specific, claim-specific approach.

Two Possible Approaches

Build an Automated Universal Rule Workflow

This approach involves creating rules within the claim scrubber that apply holds on claims involving products requiring a 340B modifier. These rules are updated quarterly and are designed to automate the process as much as possible. While efficient, this method risks over-reporting, as it applies broad criteria to all claims. This rule is faster but risks overreporting.

Build a Semi-Automated, Claim-Specific Workflow

This more detailed method refers billers to an identification tool within the claim scrubber. This tool helps determine whether a specific claim used 340B inventory, ensuring a higher accuracy level and telling the biller exactly what modifier to apply.

To do this we construct a bridge between the 340B TPA data and the billing team OR the claim scrubber. This approach allows for more precise control, catering to the needs of each claim and patient. This method is slower but more accurate.

Workflow Implementation

In both workflows, the claim scrubber evaluates the claims post-generation based on a list of products identified as requiring a 340B modifier. If the claim is clean, it’s released to the payer. If not, the appropriate hold or edit is applied.

• In the universal rule build, the scrubber automatically applies the 340B modifier based on predefined rules. This simplifies the process but may not account for the nuances of each case. This method is faster but risks over reporting.
• In the claim-specific approach, the scrubber directs the biller to check whether 340B inventory was indeed used. This is based on data collected at various intervals (monthly, weekly, or quarterly), providing a tailored response to each claim. This method is slower but more accurate.

Advantages and Support

Both methods streamline the billing process, ensuring compliance with CMS guidelines. Additionally, services like RxTrail offer assistance in building and auditing these scrubber rules, alongside providing a portal for detailed, claim-by-claim management. This support extends to integrating APIs for claim scrubbers, enhancing data exchange and processing capabilities.

Conclusion

The reinstatement of the 340B modifiers for Medicare Part B claims calls for efficient and accurate reporting methods. By leveraging claims scrubbing technology with these two distinct workflows, healthcare entities can ensure compliance while managing their billing processes effectively. The choice between a universal rule build and a claim-specific approach depends on the entity’s specific needs and the level of detail required in their reporting.