Medical Group Basics
Name 3 wholesalers that dominate Nuvance Health/Northwell's medical practice landscape
Henry Schein, McKesson Med Surge, Besse
This occurs when drugs purchased under one class of trade are used in another setting.
What is diversion?
This factor determines whether a medical group may access 340B pricing.
What is ownership & MCR presence
This billing model is most commonly used for infused or injected drugs in medical practices.
What is buy-and-bill?
This inventory model reduces upfront cost but increases governance complexity in medical groups.
hat is consignment?
This key difference separates medical groups from HOPDs in the eyes of manufacturers and payers.
What is site of care (class of trade) designation?
This absence often leads to inconsistent medical group decision-making.
What is lack of centralized governance?
This compliance risk occurs when 340B drugs are administered outside eligible locations or patients.
Diversion
This billing failure can result in lost revenue for medical practices.
What is incomplete J-code or NDC capture?
This storage requirement is often underestimated and inappropriately managed in distributed medical practices.
What is cold-chain management?
This is the number of medical practices in the Nuvance Health system? (Bonus how many are in Northwell Health's ecosystem)
150 (1100)
This action performed by manufacturers can result from non-compliant medical group purchasing.
What is contract termination, chargebacks, or repayment demand?
This relationship is often scrutinized when medical practices dispense or administer 340B drugs.
What is a contract pharmacy arrangement?
What is the major billing differences between Medical Practices and the Hospital system?
DRG versus separatable reimbursable action
This specialty drug challenge arises when manufacturers restrict distribution channels.
What are limited distribution drugs (LDDs)?
This drug manufactured by Novartis was Nuvance Health's largest spend in 2025 in our medical practices? (Hint it is used to lower LDL)
Leqvio
This operational weakness commonly increases compliance risk across multiple medical practices vs retail pharmacies
What is lack of inventory segregation or tracking?
This missing control commonly leads to adverse audit findings in medical groups.
What is insufficient auditable records tying drug to eligible patient and location?
This reimbursement model pays practices for each individual service provided.
What is fee-for-service?
This decision balances access, compliance, and financial control for high-cost therapies.
When should drugs flow through health-system specialty pharmacy versus direct-to-practice?
This reason explains why manufacturers treat medical groups differently in purchasing
What is differences in purchasing intent, utilization patterns, and site-of-care economics?
This documentation is critical during an audit to prove compliant medical group purchasing.
What is drug purchase history, administration records, and site-of-care validation data?
What strategy is leveraged for a medical practice to receive 340B pricing even though they are not a registered 340B site?
Clear bagging
This portion of the claim determines how a physician service is reimbursed based on complexity and time.
What is an Evaluation & Management (E/M) code?
What is the highest cost specialty indication (disease state) that is witnessed in the medical practices today? What is second?
1st: Oncology
2nd: Inflammatory