Will State Force Family Planning Clinics To Close?

$26.02: Is that a lot?

The price family planning providers are charging Medicaid is typically well below the maximum reimbursement pharmacies can charge the program for the same drugs.

Waloway cited an example. A month’s worth of Yaz, a popular oral contraceptive, costs her clinic $4.46 wholesale; as a 340B provider, she can charge Medicaid $26.02. A pharmacy would have to buy the pack at a higher price, so it can charge Medicaid a maximum of $124.88.

Pharmacies can charge Medicaid $49.28 for a pack of a low-dose pill, Lutera. NEWCAP buys them at $1.76 wholesale for a monthly pack, and charges Medicaid $26.02.

Where would the costs go?

The state said the clinics should have entered the actual cost of each drug for each claim. But the providers counter that there’s no place to do that in the state’s own computer system.

After the audit began, a newly hired NEWCAP budget staffer called the state’s hotline for Medicaid providers and asked how to enter the cost correctly.

Hotline staffers told her there was no way to enter it, according to NEWCAP’s Waloway.

White said he had been told that either the paper or electronic billing system was “limited” in how costs could be entered, but said, “I wouldn’t be able to give you a correct answer at this time.”

Proportionality of audits defended

Auditors are seeking some money back over what is essentially a paperwork violation: missing National Drug Codes.

NDCs are used to determine rebates that pharmaceutical companies must pay to Medicaid. But in the 340B program, because the drugs are already discounted, no rebate is paid.

The state nonetheless requires the code for provider-administered drugs.

The providers questioned whether it was fair for auditors to recoup the entire claim for these errors.

White said federal and state law require it.

“Our obligation is to seek recovery,” he said.

That approach to audits scared NEWCAP off from expanding its safety-net services this year, Waloway said.

NEWCAP was hoping to start providing prenatal care coordination to low-income women in Oconto County. Medicaid reimburses clinics a lump sum for pregnancies, no matter what services they provide.

Then Waloway learned that another community action agency was being audited for its prenatal care coordination — and had to return all the money for pregnancies where their documentation was imperfect. NEWCAP put its plans on hold.

“The reimbursement right now is very low to start with, but if they’re going to recoup all the money it’s not going to be worth it,” she said.

The nonprofit Wisconsin Center for Investigative Journalism (www.WisconsinWatch.org) collaborates with Wisconsin Public Radio, Wisconsin Public Television, other news media and the UW-Madison School of Journalism and Mass Communication. All works created, published, posted or disseminated by the Center do not necessarily reflect the views or opinions of UW-Madison or any of its affiliates.

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