06 HB
1371/AP
House
Bill 1371 (AS PASSED HOUSE AND SENATE)
By:
Representatives Graves of the
137th,
Carter of the
159th,
Harbin of the
118th,
Stephens of the
164th,
and Parrish of the
156th
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Chapter 4 of Title 26 of the Official Code of Georgia Annotated, relating
to pharmacists and pharmacies, so as to enact "The Pharmacy Audit Bill of
Rights"; to provide for a short title; to set out a list of rights of pharmacies
undergoing audits; to provide for an appeal process; to provide for
applicability; to provide for an effective date; to provide for related matters;
to repeal conflicting laws; and for other purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Chapter
4 of Title 26 of the Official Code of Georgia Annotated, relating to pharmacists
and pharmacies, is amended by adding a new Code section to the end of Article 6,
relating to pharmacies, to read as follows:
"26-4-118.
(a)
This Code section shall be known and may be cited as 'The Pharmacy Audit Bill of
Rights.'
(b)
Notwithstanding any other law, when an audit of the records of a pharmacy is
conducted by a managed care company, insurance company, third-party payor, the
Department of Community Health under Article 7 of Chapter 4 of Title 49, or any
entity that represents such companies, groups, or department, it shall be
conducted in accordance with the following bill of rights:
(1)
The entity conducting the initial on-site audit must give the pharmacy 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 must be conducted by
or in consultation with a pharmacist;
(3)
Any clerical or record-keeping error, such as a typographical error,
scriveneŕs
error, or computer error, regarding a required document or record may not in and
of itself constitute fraud; however, 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; however, recoupment of claims must 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 30 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 may 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 Department of Community Health under Article 7 of Chapter
4 of Title 49, or any entity that represents such companies, groups, or
department;
(9)
An audit may not be initiated or scheduled during the first seven calendar days
of any month due to the high volume of prescriptions filled during that time
unless otherwise consented to by the pharmacy;
(10)
The preliminary audit report must be delivered to the pharmacy within 120 days
after conclusion of the audit. A final audit report shall be delivered to the
pharmacy within six months after receipt of the preliminary audit report or
final appeal, as provided for in subsection (c), whichever is later;
and
(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 agency conducting the audit shall not use the
accounting practice of extrapolation in calculating recoupments or penalties for
audits.
(c)
Recoupments of any disputed funds shall only occur after final internal
disposition of the audit, including the appeals process as set forth in
subsection (d) of this Code section.
(d)
Each entity conducting an audit shall establish an appeals process under which a
pharmacy may appeal an unfavorable preliminary audit report to the entity. If,
following the appeal, the entity finds that an unfavorable audit report or any
portion thereof is unsubstantiated, the entity shall dismiss the audit report or
said portion without the necessity of any further proceedings.
(e)
Each entity conducting an audit shall provide a copy of the final audit report,
after completion of any review process, to the plan sponsor.
(f)
This Code section shall not apply to any investigative audit which involves
fraud, willful misrepresentation, or abuse including without limitation
investigative audits under Article 7 of Chapter 4 of Title 49, Code Section
33-1-16, or any other statutory provision which authorizes investigations
relating to insurance
fraud."
SECTION
2.
This
Act shall become effective upon its approval by the Governor or upon its
becoming law without such approval.
SECTION
3.
All
laws and parts of laws in conflict with this Act are repealed.