SECOND REGULAR SESSION
94TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVES SATER (Sponsor), WALLACE AND WELLS (Co-sponsors).
Pre-filed December 3, 2007 and copies ordered printed.
D. ADAM CRUMBLISS, Chief Clerk
AN ACT
To amend chapter 338, RSMo, by adding thereto one new section relating to pharmacists and pharmacies.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 338, RSMo, is amended by adding thereto one new section, to be known as section 338.600, to read as follows:
338.600. 1. This section shall be known and may be cited as the "Pharmacy Audit Bill of Rights Act of 2008".
2. Notwithstanding any other provision of law to the contrary, when an audit of the records of a pharmacy licensed in this state is conducted by a managed care company, insurance company, third-party payor, the department of insurance, the board of pharmacy, or any entity that represents such companies, groups, department, or board, such audit shall be conducted in accordance with the following bill of rights:
(1) The entity conducting the initial on-site audit shall provide the pharmacy with notice at least one week prior to conducting the initial on-site audit for each audit cycle;
(2) Any audit which involves clinical or professional judgment shall be conducted by or in consultation with a licensed pharmacist;
(3) Any clerical or recordkeeping error, such as a typographical error, scriveners error, or computer error, regarding a required document or record shall not in and of itself constitute fraud; except that, such claims may be subject to recoupment. No such claim shall be subject to criminal penalties without proof of intent to commit fraud;
(4) A pharmacy may use the records of a hospital, physician, or other authorized practitioner of the healing arts for drugs or medicinal supplies written or transmitted by any means of communication for purposes of validating the pharmacy record with respect to orders or refills of a legend or narcotic drug;
(5) A finding of an overpayment or underpayment may be 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; except that, recoupment of claims shall be based on the actual overpayment or underpayment unless the projection for overpayment or underpayment is part of a settlement as agreed to by the pharmacy;
(6) Each pharmacy shall be audited under the same standards and parameters as other similarly situated pharmacies audited by the entity;
(7) A pharmacy shall be allowed at least thirty days following receipt of the preliminary audit report in which to produce documentation to address any discrepancy found during an audit;
(8) The period covered by an audit shall not exceed two years from the date the claim was submitted to or adjudicated by a managed care company, insurance company, third-party payor, the state of Missouri, or any entity that represents such companies or groups, or the state of Missouri;
(9) An audit shall not be initiated or scheduled during the first seven calendar days of any month due to the high volume of prescriptions filled during such time unless otherwise consented to by the pharmacy;
(10) The preliminary audit report shall be delivered to the pharmacy within one hundred twenty days after conclusion of the audit. A final audit report shall be delivered to the pharmacy within six months of receipt of the preliminary audit report or final appeal, as provided for in subsection 3 of this section;
(11) The audit criteria set forth in this subsection shall apply only to audits of claims submitted for payment after July 1, 2006. Notwithstanding any other provision in this subsection, the entity conducting the audit shall not use the accounting practice of extrapolation in calculating recoupments or penalties for audits.
3. Recoupments of any disputed moneys shall only occur after final internal disposition of the audit, including the appeals process set forth in subsection 4 of this section.
4. Each entity conducting an audit shall establish an appeals process under which a licensed pharmacy may appeal an unfavorable preliminary audit report to the entity. If, following such appeal, the entity finds that an unfavorable audit report or any portion thereof is unsubstantiated, the entity shall dismiss the audit report or such portion without the necessity of any further proceedings.
5. Each entity conducting an audit shall provide a copy of the final audit report, after completion of any review process, to the plan sponsor.
6. This section shall not apply to any investigative audit which involved fraud, willful misrepresentation, or abuse.
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