06 LC 33
1456S
The House Committee on Insurance offers the following substitute to HB
1371:
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 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 audit must give the pharmacy notice at least one week
prior to conducting the initial audit for each audit cycle;
(2)
Any audit which involves clinical or professional judgment must be conducted by
a pharmacist licensed in this state;
(3)
Any clerical or record keeping error, such as a typographical error,
scriveneŕs
error, or computer error, regarding a required document or record shall not
constitute a willful violation and is not subject to criminal penalties without
proof of intent to commit fraud;
(4)
A pharmacy may use the
physiciańs
record or other order 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 must be based on the actual
overpayment or underpayment and may not 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;
(6)
Each pharmacy shall be audited under the same standards and parameters as other
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 five days of any
month due to the high volume of prescriptions filled during that
time;
(10) An entity conducting an audit shall not be remunerated for services based on the amount of funds identified to be recouped;
(10) An entity conducting an audit shall not be remunerated for services based on the amount of funds identified to be recouped;
(11)
The preliminary audit report must be delivered to the pharmacy within 90 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
(12) 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.
(12) 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)
Each entity conducting an audit shall establish a process under which a pharmacy
may obtain a preliminary review of an audit report and may appeal an unfavorable
audit report without the necessity of obtaining legal counsel. The preliminary
review and appeal may be conducted by an ad hoc peer review panel, appointed by
the entity, which consists of pharmacists who maintain an active practice in
this state. If, following the preliminary review, the entity or review panel
finds that an unfavorable audit report is unsubstantiated, the entity shall
dismiss the audit report without the necessity of any further proceedings.
(d)
Each entity conducting an audit shall provide a copy of the final audit report,
after completion of any review process, to the plan sponsor.
(e)
This Code section shall not apply to any investigative audit which involves
fraud, willful misrepresentation, or abuse under Article 7 of Chapter 4 of Title
49."
SECTION
2.
All
laws and parts of laws in conflict with this Act are repealed.