Florida Senate - 2022                                    SB 1476
       By Senator Wright
       14-00145A-22                                          20221476__
    1                        A bill to be entitled                      
    2         An act relating to prescription drug coverage;
    3         amending s. 624.3161, F.S.; authorizing the Office of
    4         Insurance Regulation to examine pharmacy benefit
    5         managers; specifying that certain examination costs
    6         are payable by persons examined; amending s. 624.490,
    7         F.S.; providing a penalty for failure to register as a
    8         pharmacy benefit manager under certain circumstances;
    9         transferring, renumbering, and amending s. 465.1885,
   10         F.S.; revising the entities conducting pharmacy audits
   11         to which certain requirements and restrictions apply;
   12         authorizing audited pharmacies to appeal certain
   13         findings; providing that health insurers and health
   14         maintenance organizations that transfer a certain
   15         payment obligation to pharmacy benefit managers remain
   16         responsible for specified violations; providing an
   17         effective date.
   19  Be It Enacted by the Legislature of the State of Florida:
   21         Section 1. Subsections (1) and (3) of section 624.3161,
   22  Florida Statutes, are amended to read:
   23         624.3161 Market conduct examinations.—
   24         (1) As often as it deems necessary, the office shall
   25  examine each pharmacy benefit manager as defined in s. 624.490;
   26  each licensed rating organization;, each advisory organization;,
   27  each group, association, carrier, as defined in s. 440.02, or
   28  other organization of insurers which engages in joint
   29  underwriting or joint reinsurance;, and each authorized insurer
   30  transacting in this state any class of insurance to which the
   31  provisions of chapter 627 are applicable. The examination shall
   32  be for the purpose of ascertaining compliance by the person
   33  examined with the applicable provisions of chapters 440, 624,
   34  626, 627, and 635.
   35         (3) The examination may be conducted by an independent
   36  professional examiner under contract to the office, in which
   37  case payment shall be made directly to the contracted examiner
   38  by the insurer or person examined in accordance with the rates
   39  and terms agreed to by the office and the examiner.
   40         Section 2. Present subsection (6) of section 624.490,
   41  Florida Statutes, is redesignated as subsection (7), and a new
   42  subsection (6) is added to that section, to read:
   43         624.490 Registration of pharmacy benefit managers.—
   44         (6)A person who fails to register with the office while
   45  operating as a pharmacy benefit manager is subject to a fine of
   46  $10,000 for each violation.
   47         Section 3. Section 465.1885, Florida Statutes, is
   48  transferred, renumbered as section 624.491, Florida Statutes,
   49  and amended to read:
   50         624.491 465.1885 Pharmacy audits; rights.—
   51         (1) A health insurer or health maintenance organization
   52  providing pharmacy benefits through a major medical individual
   53  or group health insurance policy or a health maintenance
   54  organization contract, respectively, must comply with the
   55  requirements of this section when the health insurer or health
   56  maintenance organization or any person or entity acting on
   57  behalf of the health insurer or health maintenance organization,
   58  including, but not limited to, a pharmacy benefit manager as
   59  defined in s. 624.490, audits the records of a pharmacy licensed
   60  under chapter 465. The person or entity conducting such audit
   61  must If an audit of the records of a pharmacy licensed under
   62  this chapter is conducted directly or indirectly by a managed
   63  care company, an insurance company, a third-party payor, a
   64  pharmacy benefit manager, or an entity that represents
   65  responsible parties such as companies or groups, referred to as
   66  an “entity” in this section, the pharmacy has the following
   67  rights:
   68         (a) Except as provided in subsection (3), notify the
   69  pharmacy To be notified at least 7 calendar days before the
   70  initial onsite audit for each audit cycle.
   71         (b) Not schedule an To have the onsite audit during
   72  scheduled after the first 3 calendar days of a month unless the
   73  pharmacist consents otherwise.
   74         (c) Limit the duration of To have the audit period limited
   75  to 24 months after the date a claim is submitted to or
   76  adjudicated by the entity.
   77         (d) In the case of To have an audit that requires clinical
   78  or professional judgment, conduct the audit in consultation
   79  with, or allow the audit to be conducted by, or in consultation
   80  with a pharmacist.
   81         (e) Allow the pharmacy to use the written and verifiable
   82  records of a hospital, physician, or other authorized
   83  practitioner, which are transmitted by any means of
   84  communication, to validate the pharmacy records in accordance
   85  with state and federal law.
   86         (f) Reimburse the pharmacy To be reimbursed for a claim
   87  that was retroactively denied for a clerical error,
   88  typographical error, scrivener’s error, or computer error if the
   89  prescription was properly and correctly dispensed, unless a
   90  pattern of such errors exists, fraudulent billing is alleged, or
   91  the error results in actual financial loss to the entity.
   92         (g) Provide the pharmacy with a copy of To receive the
   93  preliminary audit report within 120 days after the conclusion of
   94  the audit.
   95         (h) Allow the pharmacy to produce documentation to address
   96  a discrepancy or audit finding within 10 business days after the
   97  preliminary audit report is delivered to the pharmacy.
   98         (i) Provide the pharmacy with a copy of To receive the
   99  final audit report within 6 months after the pharmacy’s receipt
  100  of receiving the preliminary audit report.
  101         (j) Calculate any To have recoupment or penalties based on
  102  actual overpayments and not according to the accounting practice
  103  of extrapolation.
  104         (2) The rights contained in This section does do not apply
  105  to:
  106         (a) Audits in which suspected fraudulent activity or other
  107  intentional or willful misrepresentation is evidenced by a
  108  physical review, review of claims data or statements, or other
  109  investigative methods;
  110         (b) Audits of claims paid for by federally funded programs;
  111  or
  112         (c) Concurrent reviews or desk audits that occur within 3
  113  business days after of transmission of a claim and where no
  114  chargeback or recoupment is demanded.
  115         (3) An entity that audits a pharmacy located within a
  116  Health Care Fraud Prevention and Enforcement Action Team (HEAT)
  117  Task Force area designated by the United States Department of
  118  Health and Human Services and the United States Department of
  119  Justice may dispense with the notice requirements of paragraph
  120  (1)(a) if such pharmacy has been a member of a credentialed
  121  provider network for less than 12 months.
  122         (4)Pursuant to s. 408.7057, and after receipt of the final
  123  audit report issued under paragraph (1)(i), a pharmacy may
  124  appeal the findings of the final audit report as to whether a
  125  claim payment is due and as to the amount of a claim payment.
  126         (5)A health insurer or health maintenance organization
  127  that, under terms of a contract, transfers to a pharmacy benefit
  128  manager the obligation to pay a pharmacy licensed under chapter
  129  465 for any pharmacy benefit claims arising from services
  130  provided to or for the benefit of an insured or subscriber
  131  remains responsible for a violation of this section.
  132         Section 4. This act shall take effect July 1, 2022.