WSHA and the American Hospital Association (AHA) strongly recommend hospitals impacted by the 340B payment cuts take steps to preserve their right to the prior payment level by appealing claims. The AHA, hospitals and their associations are currently engaged in litigation with the Centers for Medicare and Medicaid Services (CMS) to reverse the 2018 cut to Medicare payment for 340B drugs. WSHA submitted an Amicus Curiae brief in support of the hospitals. AHA is concerned that even if the lawsuit is successful, unless hospitals taken steps to appeal the reduced payment amounts, CMS will claim hospitals have effectively accepted the lower payments.
To appeal, hospitals must submit requests for redetermination of the specific claims where the hospital received the reduced payment. An appeal must be submitted to the Medicare Administrative Contractor (MAC) within 120 days of the initial payment. AHA has provided a set of instructions and forms for use by hospitals available on a the AHA website.
WSHA was recently told by a member hospital that has submitted redetermination requests that Noridian is currently denying their redetermination requests, saying the claims were properly paid based on CMS instructions. This is consistent with what AHA has heard from other MACs. Once a determination request is denied by the MAC, the hospital must submit a request for reconsideration of the claim to the Qualified Independent Contractor (QIC) within 120 days of the redetermination denial to keeps its appeal open. The purpose of the appeals is to protect the hospital’s right to corrected payment in the event the lawsuit is successful. Otherwise, CMS may apply the original 340B payment level only to claims occurring after the date of a successful court decision. We recommend that hospitals continue to submit redetermination requests for reduced claims and file subsequent appeals until the situation has been resolved by the courts or through legislation. WSHA will keep hospitals informed of any new developments. (Andrew Busz, firstname.lastname@example.org).