General CEU: Hospital Systems as Employer/Plan Sponsors and 340B Covered Entities: Unique Opportunities to Audit PBMs and PBM-Owned Contract Pharmacies

Hospital Systems as Employer/Plan Sponsors and 340B Covered Entities: Unique Opportunities to Audit PBMs and PBM-Owned Contract Pharmacies matters because it changes what a BCBA notices when decisions have to hold up in joint consultation, shared care planning, school-team communication, and interdisciplinary handoffs. In Hospital Systems as Employer/Plan Sponsors and 340B Covered Entities: Unique Opportunities to Audit PBMs and PBM-Owned Contract Pharmacies, for this course, the practical stakes show up in clearer roles, fewer duplicated efforts, and better coordinated intervention, not in abstract discussion alone.

Provider: BehaviorLive — via AVBCC

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Course Description

Vertical integration allows PBMs to earn secret profits in the context of both 340B contract pharmacy relationships and employee benefit design. Providers and Employers/Plans must remain vigilant and audit PBMs. Hospital systems interact with PBMs in the Hospital's capacity as both an Employer/Plan Sponsor of a self-funded employee health benefit plan, and as a 340B Covered Entity contracting with a PBM-owned specialty pharmacy. In the context of pharmacy benefit design for Hospitals/employers, PBMs often retain manufacturer rebate "spread", increasing Plan costs. PBMs conceal data that would otherwise reveal the flow of funds between stakeholders, including: information between drug manufacturers and the rebate aggregators; between the rebate aggregators and the PBMs; and between the PBMs and pharmacies. As Plan Sponsors, hospital systems owe a fiduciary obligation to employees to ensure that the PBMs are not charging unreasonable costs. Hospitals should "audit" their PBM. Some PBMs have turned their focus on profiting off the 340B program through exploitation of typical 340B "contract pharmacy" arrangements. Contract pharmacies owned by PBMs are able to secretly divert 340B savings from the covered entity (the hospital) to the PBM. Accordingly, hospital systems that rely on 340B revenue to fund charitable patient care must audit the PBMs and their affiliated contract pharmacies to ensure that they are receiving 340B savings as Congress intended. Hospital systems that serve as both a 340B covered entity and a Plan Sponsor are uniquely positioned to identify PBM underpayments and overcharges. Health systems have visibility into both what the Hospital is paying for its own employee drug claims (as a plan sponsor) and the PBM drug reimbursement paid to the Hospital's pharmacy, for the Hospital employee claims. "Triangulating" reimbursement data will uncover unauthorized "spread pricing". Hospitals must also audit the 340B relationship with the PBM-owned contract pharmacy.

What You'll Learn

1. Identify the key steps in the credentialing lifecycle from initial application through recredentialing.
2. Describe common payer pitfalls in the credentialing process and strategies to avoid them.
3. Evaluate how credentialing status impacts billing, reimbursement, and audit risk for ABA providers.

CEU Credits Earned

Certification Body	Credits	Type
BACB	1	General

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