Supporting Your Program Integrity, HRSA Audit Readiness, and Long-Term Pharmacy Success
340B compliance, audit readiness, and program integrity
AAFCPAs’ Healthcare practice has deep expertise in federal 340B program compliance. We help you prepare, ensure program integrity, and mitigate major risks.
The Health Resources & Services Administration (HRSA) 340B Program has a myriad of regulations and compliance requirements, which often leave covered entities feeling overwhelmed and concerned. HRSA recently switched their audit focus from commercial hospital environments to nonprofit covered entities and contract pharmacy arrangements. A finding of non-compliance can result in sanctions, removal from the Program, and/or repayment to manufacturers. Additionally, HRSA has recently clarified that covered entities utilizing a contract pharmacy are required to have an annual independent audit of the Program.
AAFCPAs’ Healthcare practice has deep expertise in federal 340B program compliance. We help clients:
Flexible solutions tailored to your 340B compliance needs
Whether you need a comprehensive program assessment, targeted compliance testing, ongoing monitoring, or support strengthening policies and controls, AAFCPAs offers scalable 340B solutions designed to improve program integrity, reduce risk, and support audit readiness.
340B experience that extends beyond compliance
Why Healthcare Organizations Choose AAFCPAs for 340B Advisory
340B compliance requires practical experience with FQHC operations, pharmacy oversight, audit readiness, data analysis, and evolving program requirements. Since the launch of the 340B Program in 1992, AAFCPAs has helped healthcare organizations strengthen compliance, reduce risk, and maximize the value of their 340B participation.
AAFCPAs’ Healthcare practice has been involved with the 340B Drug Pricing Program since the launch in 1992. We conduct regular 340B Compliance training sessions for clients and membership associations, and help covered entities avoid common pitfalls and major compliance risks associated with running your 340B pharmacy.
All of the Federally Qualified Health Centers (FQHCs) we work with participate in the 340B program. Our understanding of the operations of FQHCs is integral in assessing risks related to the 340B program and pharmacy procedures.
Our Healthcare Practice leaders are members and active participants of the 340B University, an HRSA-endorsed training program, which provides us with the best possible knowledge to keep you informed of the latest trends and opportunities to optimize the value of the 340B program products, services, and tools. We have access to a multitude of resources through the University, ranging from your FQHC peers to pharmaceutical distributors, and we have direct access to the OPA, which we utilize as needed to help clients implement best practices.
We understand the unique business challenges associated with managing both in-house and contract pharmacies including increased risk of noncompliance, measurement of performance of each pharmacy, and the increased staffing and reporting burden. We advise clients on maximizing capture rates while ensuring profits are maintained in alignment with 340B program criteria.
We understand the unique business challenges associated with managing both in-house and contract pharmacies including increased risk of noncompliance, measurement of performance of each pharmacy, and the increased staffing and reporting burden. We advise clients on maximizing capture rates while ensuring profits are maintained in alignment with 340B program criteria.
AAFCPAs leverages the specialized skills of our in-house Data Analysts, state-of-the-art technologies, and proven methodologies to extract, inspect, cleanse, and model client data to discover meaningful information that supports better decision making.
We leverage the deep resources of our 350+ person CPA and consulting firm, as well as national and global resources, to deliver meaningful audit and consulting engagements.
We believe that proactive and open communication with our clients will always be the key to success in delivering outstanding consulting services.
Population-Level Transaction Monitoring
AAFCPAs leverages our healthcare and data analytics expertise to assess your entire population of pharmacy transactions for a limited number of compliance requirements including:
*Satisfies independent audit requirements as outlined by HRSA.
Independent Compliance Testing and Validation
In cases where covered entities do not have access to the entire population of pharmacy transactions, AAFCPAs selects a representative sample of pharmacy transactions and performs detailed testing of the various HRSA criteria, including:
*Satisfies independent audit requirements as outlined by HRSA.
Ongoing Monitoring for Emerging Compliance Risks
AAFCPAs performs Monthly Outlier Reporting for covered entities who have multiple contract pharmacy arrangements or a significant amount of contract pharmacy transactions. We leverage our healthcare and data analytics expertise as well as state-of-the-art data extraction software to export, summarize, review, and analyze thousands of prescription transactions in a cost-efficient manner. This analysis includes information related to:
*Satisfies independent audit requirements as outlined by HRSA.
Evaluating the Controls That Support Program Integrity
AAFCPAs assesses the design of your 340B pharmacy program policies and procedures and their ability to meet internal control objectives. These assessments include detailed, live walkthroughs of pharmacy transactions to determine if controls are operating as designed. AAFCPAs recommends Internal Control Policies and Procedures Assessment be performed every three years, or when there are significant changes in your pharmacy program, such as expansion of service providers or locations.
Assessing the Foundation of 340B Compliance
AAFCPAs assesses the design of your 340B pharmacy policies and their ability to meet compliance objectives, including but not limited to:
AAFCPAs recommends Compliance Policies and Procedures Assessments be performed every three years, or when there are significant changes in your pharmacy program, e.g. expansion of service providers or locations.
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AAFCPAs would like to make clients aware that legislation designed to overhaul the 340B program was recently introduced. This legislation, previously coined the 340B Affording…
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