An Act Regarding Pharmacy Provider Audits
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §4317, sub-§10, ¶¶F to M are enacted to read:
F. The auditor may recoup only the dispensing fee in the calculation of an overpayment unless the prescription is considered a misfill.
G. The auditor may not recoup funds for a clerical or record-keeping error in a prescription, which includes a typographical error, scrivener's error or computer error on a required document or record.
H. The auditor may not collect any funds, charge-backs or penalties until the audit is complete and all appeals by the pharmacy are exhausted and final.
I. Except as required for compliance with state or federal law, an auditor may have access to previous audit reports on a pharmacy only if the previous audit was conducted by the same auditor.
J.
A pharmacy subject to an audit may use the following records to validate a claim for a prescription, refill or change in a prescription:
(1) Electronic or physical copies of records of a health care facility or a health care provider with prescribing authority; and
(2) Any prescription that complies with state law.
K. The auditor may not audit claims submitted more than 12 months prior to the audit, unless required by federal law.
L. Prior to an audit the auditor must give the pharmacy 10 days' advance written notice of the audit and the range of prescription numbers or the range of dates included in the audit.
M. To preserve the neutrality of an audit, the auditor must use a fair and representative sample of random pharmacy transactions in an audit. Product selection and cost may not be used to influence which products the auditor chooses to audit.
summary
This bill limits the total amount that may be recouped in pharmacy audits to dispensing fees, unless a misfill occurs. The bill prohibits collection of amounts due as a result of an audit until the audit is complete and appeals are exhausted, unless there is evidence of pharmacy fraud or intentional or willful misrepresentation. The bill also limits access by pharmacy auditors to certain records, requires auditors to give advance notice of an audit and requires the random sampling of pharmacy transactions.