HB 1149

1	A bill to be entitled
2	An act relating to audits of pharmacy records; amending s.
3	465.188, F.S.; revising requirements for the audit of
4	Medicaid-related pharmacy records; authorizing third-party
5	payor and third-party administrator audits of pharmacies;
6	providing that claims containing certain clerical or
7	recordkeeping errors are not subject to financial
8	recoupment under certain circumstances; specifying that
9	certain audit criteria apply to third-party claims
10	submitted after a specified date; prohibiting certain
11	accounting practices used for calculating the recoupment
12	of claims; prohibiting the audit criteria from requiring
13	the recoupment of claims except under certain
14	circumstances; providing procedures for the audit of
15	third-party payor and third-party administrator audits;
16	providing an effective date.
17
18	Be It Enacted by the Legislature of the State of Florida:
19
20	Section 1.  Section 465.188, Florida Statutes, is amended
21	to read:
22	465.188  Medicaid financial audits of pharmacies.-
23	(1)  Notwithstanding any provision of other law, when an
24	audit of the Medicaid-related, third-party payor, or third-party
25	administrator records of a pharmacy permittee licensed under
26	this chapter 465 is conducted, such audit must be conducted as
27	provided in this section.
28	(a)  The agency or other entity conducting the audit must
29	give the pharmacist at least 1 week's prior notice of the
30	initial audit for each audit cycle.
31	(b)  An audit must be conducted by a pharmacist licensed in
32	this state.
33	(c)  Any clerical or recordkeeping error, such as a
34	typographical error, scrivener's error, or computer error
35	regarding a document or record required under the third-party
36	payor, third-party administrator, or Medicaid program does not
37	constitute a willful violation and, without proof of intent to
38	commit fraud, is not subject to criminal penalties without proof
39	of intent to commit fraud. A claim is not subject to financial
40	recoupment if, except for such a clerical or recordkeeping
41	error, the claim is an otherwise valid claim.
42	(d)  A pharmacist may use the physician's record or other
43	order for drugs or medicinal supplies written or transmitted by
44	any means of communication for purposes of validating the
45	pharmacy record with respect to orders or refills of a legend or
46	narcotic drug.
47	(e)  A finding of an overpayment or underpayment must be
48	based on the actual overpayment or underpayment and may not be a
49	projection based on the number of patients served having a
50	similar diagnosis or on the number of similar orders or refills
51	for similar drugs.
52	(f)  Each pharmacy shall be audited under the same
53	standards and parameters.
54	(g)  A pharmacist must be allowed at least 10 days in which
55	to produce documentation to address any discrepancy found during
56	an audit.
57	(h)  The period covered by an audit may not exceed 1
58	calendar year.
59	(i)  An audit may not be scheduled during the first 5 days
60	of any month due to the high volume of prescriptions filled
61	during that time.
62	(j)  The audit report must be delivered to the pharmacist
63	within 90 days after conclusion of the audit. A final audit
64	report shall be delivered to the pharmacist within 6 months
65	after receipt of the preliminary audit report or final appeal,
66	as provided for in subsection (2), whichever is later.
67	(k)  The audit criteria set forth in this section apply
68	applies only to audits of Medicaid claims submitted for payment
69	after subsequent to July 11, 2003, and to third-party claims
70	submitted for payment after July 1, 2009. Notwithstanding any
71	other provision of in this section, the agency or other entity
72	conducting the audit shall not use the accounting practice of
73	extrapolation in calculating penalties or recoupment for
74	Medicaid, third-party payor, or third-party administrator
75	audits.
76	(l)  The audit criteria may not subject a claim to
77	financial recoupment except in those circumstances when
78	recoupment is required by law.
79	(2)  The Agency for Health Care Administration, in the case
80	of a Medicaid-related audit, or the third-party payor or third-
81	party administrator contracting with the pharmacy, in the case
82	of a third-party payor or third-party administrator audit, shall
83	establish a process under which a pharmacist may obtain a
84	preliminary review of an audit report and may appeal an
85	unfavorable audit report without the necessity of obtaining
86	legal counsel. The preliminary review and appeal may be
87	conducted by an ad hoc peer review panel, appointed by the
88	agency, in the case of a Medicaid-related audit, or appointed by
89	the third-party payor or third-party administrator contracting
90	with the pharmacy, in the case of a third-party payor or third-
91	party administrator audit, which consists of pharmacists who
92	maintain an active practice. If, following the preliminary
93	review, the agency or review panel finds that an unfavorable
94	audit report is unsubstantiated, the agency, in the case of a
95	Medicaid-related audit, or the third-party payor or third-party
96	administrator contracting with the pharmacy, in the case of a
97	third-party payor or third-party administrator audit, shall
98	dismiss the audit report without the necessity of any further
99	proceedings.
100	(3)  This section does not apply to investigative audits
101	conducted by the Medicaid Fraud Control Unit of the Department
102	of Legal Affairs.
103	(4)  This section does not apply to any investigative audit
104	conducted by the Agency for Health Care Administration when the
105	agency has reliable evidence that the claim that is the subject
106	of the audit involves fraud, willful misrepresentation, or abuse
107	under the Medicaid program.
108	Section 2.  This act shall take effect upon becoming a law.

CODING: Words stricken are deletions; words underlined are additions.