No. HB 1209
Filed under Insurance.
Pharmacy Audits; Revises requirements for audits of licensed pharmacies conducted by or on behalf of pharmacy benefit plans or programs; revises audit procedures, documentation requirements, recoupment limits, & reporting & appeal requirements; provides procedures for conducting audits of fraud, waste, or abuse; provides for enforcement; authorizes OIR to impose fines & other administrative penalties; authorizes suspension or revocation of pharmacy benefit manager's registration; requires FSC to adopt rules.
Plain English Summary
AI-GENERATEDAuditors working for pharmacy benefit plans may examine no more than 0.1 percent of a pharmacy's prescriptions at random, and can only pick specific claims to review if they document a real suspicion of fraud, waste, or abuse.
Recoupment for most errors is capped at the pharmacy's dispensing fee; taking back the drug's own cost requires proof the pharmacy failed to dispense it or committed fraud, and every dollar recouped must go back to the plan sponsor.
Auditors can't treat independent pharmacies more harshly than ones the PBM itself owns, can't be paid based on how much they recover, and must give 30 days' written notice, up from seven, before an audit.
The state office enforcing this law can now fine violators up to $100,000 per offense, order restitution, bar repeat offenders from auditing for two years, and suspend or revoke a pharmacy benefit manager's registration.
AIExcept where the pharmacy failed to dispense the drug or acted with willful intent to defraud, an auditor may only claw back the dispensing fee, not the cost of the drug itself.
AIAn auditor or pharmacy benefit manager cannot keep money it recoups from a pharmacy; every dollar clawed back must be paid over in full to the employer or entity sponsoring the benefit plan.
AIAn auditor may examine no more than one-tenth of one percent of a pharmacy's prescriptions at random in a single audit; auditing more requires a written, documented suspicion of fraud, waste, or abuse.
AIAuditors must pick claims at random; choosing which claims to review based on drug class, cost, or therapeutic category is barred unless fraud, waste, or abuse is reasonably suspected and documented in writing.
AIAn auditor cannot apply stricter methods, higher error thresholds, more paperwork demands, or more frequent audits to pharmacies outside the pharmacy benefit manager's own network than it applies to its own affiliated pharmacies.
AIWhoever conducts a pharmacy audit cannot be paid based on how much money the audit recovers, removing the financial incentive to maximize recoupments regardless of accuracy.
AIThe state's insurance regulator can now fine an auditor up to $100,000 per violation for abusing the fraud designation, order restitution, and suspend or revoke a pharmacy benefit manager's registration for repeated or willful violations.
AIAn entity cannot invoke a fraud, waste, or abuse designation to escape this section's audit limits unless the audit actually satisfies the separate documentation and notice requirements that apply to fraud audits specifically.