At a Glance
After CMS announced that PrEP would be completely covered by Medicare Part B, a respected nonprofit healthcare system jumped at the chance to help their patients get the HIV prevention they need. But when other vendors were unable to bill with 340B modifiers, the health system turned to EnlivenHealth. Working together, EnlivenHealth was able to help the health system navigate PrEP billing and successfully submit claims for their patients.
Background
On September 30th, 2024, CMS announced that pre-exposure prophylaxis (PrEP) would be covered by Medicare Part B, making HIV preventive treatment more accessible for millions of people nationwide. One nonprofit community health system saw an opportunity for the tens of thousands of patients they serve in the Appalachian and Southwest regions of the United States and acted immediately. Unfortunately, the billing changes weren’t exactly smooth sailing.
“These claims were complicated, and they took a significant amount of time to work through,” said the health system’s director of pharmacy operations.
Seeking help with these medical billing claims, the director discovered that not only could EnlivenHealth help them bill for PrEP, they could also bill with 340B modifiers — something no other medical billing vendor was capable of doing. The team at EnlivenHealth was able to help the health system successfully bill and get reimbursed for PrEP, working hand-in-hand with the director on some of their most troublesome claims.
“We were able to trial and error claims together and really work to get these claims through. Medical billing is difficult and nuanced, but the customer service team makes it better!”
Director of Pharmacy Operations
Challenges
New Billing Procedures: Moving PrEP coverage to Part B meant a different billing procedure for the pharmacy to be reimbursed for treatment.
Complex Billing Requirements: Getting reimbursed for medical claims or DME is very different from prescription reimbursement — and often more complicated.
Difficulties with 340B Billing: Previous vendors that the health system had worked with were unable to bill with 340B modifiers.
Solution: Cardinal Health Medical Benefit Billing (powered by EnlivenHealth)
Cardinal Health Medical Benefit Billing (powered by EnlivenHealth) enables pharmacies to bill and track medical benefit and DME claims in real time, including 340B modifiers. It offers visibility into all applicable medical claims, including secondary claims and pre-submission edits, and it helps the pharmacy team save time with built-in automations, queues, and quick actions. Plus, the dedicated billing support team is available to answer questions and help work through even the toughest issues that can come up.
Results
Expanded Clinical Revenue: With PrEP treatment accounting for nearly 58% of medical claims submissions across all its pharmacies, the nonprofit health system embraced Medicare’s new PrEP coverage under Part B to expand their clinical revenue while bringing a much-needed service to their patients.
Successful PrEP Claims Submission: With the help of the support team, the health system was able to successfully submit claims for PrEP medication and dispensing, including claims with 340B modifiers.
For More Information
Are you a Cardinal Health member that needs help billing the medical benefit? Have you been having problems with 340B billing? Reach out to your Cardinal Health representative or visit cardinalhealth.com for more information about Cardinal Health Medical Benefit Billing.