340B Health

340B Insight Podcast

Episode Seventy: 340B Internal Audits

March 20, 2023

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340B compliance is a critical requirement for hospitals participating in the program, and one of the ways 340B hospitals maintain compliance is through conducting internal audits. For this episode, we speak with Tristan Greer, 340B program business manager at Catholic Health in Buffalo, N.Y. Tristan has significant experience conducting 340B internal audits at the health system, and she shares several best practices for a successful internal audit. Before the interview, we provide a news update on how drug manufacturers are pursuing legislative changes to 340B and some of the responses to that proposal. (Transcript)

Show Notes

  • The Benefits of Internal Audits Internal audits help 340B covered entities stay in compliance. Tristan outlines the internal audit process her health system uses and how this supports the overall compliance effort. She also explains how the internal audit process has changed over time.
  • What HRSA Expects from Internal AuditsTristan discusses what HRSA expects hospitals to share about their 340B internal audits.
  • Staying Organized During Internal Audits Tristan shares her approach to accomplishing a successful internal audit, including which materials her hospital gathers for the process.

Check out all of our episodes on the 340B Insight podcast website. You also can stay updated on all 340B Health news and information by visiting our homepage. If you have any questions you’d like us to cover in this podcast, email us at podcast@340bhealth.org.


  1. 340B Health Statement on PhRMA Proposal to Reduce Safety-Net Hospital Participation in 340B

  2. Rep. Doris Matsui Statement on Proposal to Change 340B Program

  3. PhRMA Unveils More Details About Proposed 340B Hospital Eligibility Cuts

  4. 340B Coalition Winter Conference