Chapter 278 |
2019 -- S 0581 SUBSTITUTE A Enacted 07/16/2019 |
A N A C T |
RELATING TO BUSINESSES AND PROFESSIONS -- PHARMACIES |
Introduced By: Senators Lynch Prata, McCaffrey, and McKenney |
Date Introduced: March 14, 2019 |
It is enacted by the General Assembly as follows: |
SECTION 1. Chapter 5-19.1 of the General Laws entitled "Pharmacies" is hereby |
amended by adding thereto the following section: |
5-19.1-34 5-19.1-35. Audits. |
(a) When an on-site audit of the records of a pharmacy is conducted by a carrier or their |
its intermediary, the audit must be conducted in accordance with the following criteria: |
(1) A finding of overpayment or underpayment must be based on the actual overpayment |
or underpayment, and not a projection based on the number of patients served having a similar |
diagnosis, or on the number of similar orders or refills for similar drugs, unless the projected |
overpayment or denial is a part of a settlement agreed to by the pharmacy or pharmacist; |
(2) The auditor may not use extrapolation in calculating recoupments or penalties unless |
required by state or federal laws or regulations; |
(3) Any audit that involves clinical judgment must be conducted by, or in consultation |
with, a pharmacist; and |
(4) Each entity conducting an audit shall establish an appeal process under which a |
pharmacy may appeal an unfavorable preliminary audit report to the entity. |
(b) This section does not apply to any audit, review, or investigation that is initiated |
based on or involving suspected or alleged fraud, willful misrepresentation, or abuse. |
(c) Prior to an audit, the entity conducting an audit shall give the pharmacy fourteen (14) |
days advance written notice of the audit and the range of prescription numbers involved in the |
audit. The carrier or their its intermediary may mask the last two digits of such the numbers. |
Additionally, the number of prescriptions shall not exceed one hundred fifty (150) prescription |
claims and their applicable refills. The time allotted must be adequate to collect all samples. The |
examination of signature logs shall not exceed twenty-five (25) signature logs in number. |
(d) A pharmacy has the right to execute the dispute resolution contained in their contract. |
(e)(1) A preliminary audit report must be delivered to the pharmacy or its corporate office |
within sixty (60) days after the conclusion of the audit. A pharmacy must be allowed at least |
thirty (30) days following receipt of the preliminary audit to provide documentation to address |
any discrepancy found in the audit. A final audit report must be delivered to the pharmacy or its |
corporate office within ninety (90) days after receipt of the preliminary audit report or final |
appeal, whichever is later. A charge-back recoupment or other penalty may not be assessed until |
the appeal process provided by the pharmacy benefits manager has been exhausted and the final |
report issued. If the identified discrepancy for a single audit exceeds twenty-five thousand dollars |
($25,000), future payments in excess of that amount may be withheld pending the adjudication of |
an appeal. Auditors shall only have access to previous audit reports on a particular pharmacy |
conducted for the same entity. |
(2) Auditors may initiate a desk audit prior to an on-site audit unless otherwise specified |
in the law. |
(3) Contracted auditors cannot be paid based on the findings within an audit. |
(4) Scanned images of all prescriptions including all scheduled controlled substances are |
allowed to be used by the pharmacist for an audit. Verbally received prescriptions must be |
accepted upon validation by the auditing entity and applicable for the initial desk or on-site audit. |
(5) The period covered by an audit may not exceed two (2) years. |
(6) Within five (5) business days of receiving the audit notification, pharmacies are |
allowed, at a minimum, one opportunity to reschedule with the auditor if the scheduled audit |
presents a scheduling conflict for the pharmacist. |
(f) Any clerical error, typographical error, scrivener's error, or computer error regarding a |
document or record required under the Medicaid program does not constitute a willful violation |
and is not subject to criminal penalties without proof of intent to commit fraud. |
(g) Limitations. |
(1) Exceptions. The provisions of this chapter do not apply to an investigative audit of |
pharmacy records when: |
(i) Fraud, waste, abuse, or other intentional misconduct is indicated by physical review or |
review of claims data or statements; or |
(ii) Other investigative methods indicate a pharmacy is or has been engaged in criminal |
wrongdoing, fraud, or other intentional or willful misrepresentation. |
(2) Federal law. This chapter does not supersede any audit requirements established by |
federal law. |
SECTION 2. This act shall take effect upon passage. |
======== |
LC002040/SUB A |
======== |