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.
18
19 Be It Enacted by the Legislature of the State of Florida:
20
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.