06 LC 28
3086S
The
Senate Insurance and Labor Committee offered 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 amend Article 7 of Chapter 4 of Title 49 of the Official Code
of Georgia Annotated, relating to medical assistance generally, so as to provide
pharmacies the opportunity to cure violations of a procedural nature identified
pursuant to an audit or determination by other means prior to disallowing an
otherwise valid claim; to provide that a pharmacy shall have the opportunity for
a hearing on a violation of a procedural matter; to provide for an effective
date and 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 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
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 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 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 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
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.
Article
7 of Chapter 4 of Title 49 of the Official Code of Georgia Annotated, relating
to medical assistance generally, is amended by inserting a new Code section to
read as follows:
"49-4-152.5.
A
pharmacy providing medications pursuant to this article for medical assistance
shall be given the opportunity to cure any violation of a procedural nature
identified pursuant to an audit under Code Sections 26-4-118 or 49-4-151 or
determination by other means, including, but not limited to, the inclusion of a
default physician identifier for claims that are otherwise valid. Any such
violation of a procedural nature for a claim which is otherwise valid shall not
be deemed to be an overpayment or disallowed claim by the
department."
SECTION
3.
Said
article is further amended in Code Section 49-4-153, relating to administrative
hearings and appeals, judicial review, and contested cases involving imposition
of remedial or punitive measures against a nursing facility, by striking
subparagraph (b)(2)(A) and inserting in lieu thereof the following:
"(2)(A)
A provider of medical assistance may request a hearing on a decision of the
Department of Community Health with respect to a denial or nonpayment of or the
determination of the amount of reimbursement paid or payable to such provider on
a certain item of medical or remedial care of service rendered by such provider
by filing a written request for a hearing in accordance with Code Sections
50-13-13 and 50-13-15 with the Department of Community Health. The Department of
Community Health shall, within 15 business days of receiving the request for
hearing from the provider, transmit a copy of the
provideŕs
request for hearing to the Office of State Administrative Hearings. The
provideŕs
request for hearing shall identify the issues under appeal and specify the
relief requested by the provider. The request for hearing shall be filed no
later than 15 business days after the provider of medical assistance receives
the decision of the Department of Community Health which is the basis for the
appeal. A
pharmacy may request a hearing on a decision of the Department of Community
Health or a care management or other organization contracted by the department
with respect to a denial or nonpayment of or the determination of the amount of
reimbursement paid or payable to such pharmacy pursuant to the results of an
audit or determination by other means on a certain service rendered by such
pharmacy. A pharmacy shall be given the opportunity to cure any violation of a
procedural nature, including, but not limited to, the inclusion of a default
physician identifier for claims that are otherwise valid. Any such violation of
a procedural nature which is otherwise valid shall not be deemed to be an
overpayment or disallowed claim by the Department of Community Health or a care
management or other organization contracted by the
department."
SECTION
4.
(a)
This Act shall become effective upon its approval by the Governor or upon its
becoming law without such approval.
(b) Sections 2 and 3 of this Act shall apply to any claim submitted or pending on or after March 15, 2006.
(b) Sections 2 and 3 of this Act shall apply to any claim submitted or pending on or after March 15, 2006.
SECTION
5.
All
laws and parts of laws in conflict with this Act are repealed.