Florida 2022 Regular Session

Florida House Bill H0357 Compare Versions

Version 1 (Old)

Version 2 (New)

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9	9		Page 1 of 5
10	10		F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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14		-	1
	14	+	A bill to be entitled 1
15	15		An act relating to pharmacies and pharmacy benefit 2
16	16		managers; transferring, renumbering, and amending s. 3
17	17		465.1885, F.S.; revising the entities conducting 4
18	18		pharmacy audits to which certain requirements and 5
19	19		restrictions apply; authorizing audited pharmacies to 6
20	20		appeal certain findings; providing that health 7
21	21		insurers and health maintenance organizations that 8
22	22		transfer certain payment obligation to pharmacy 9
23	23		benefit managers remain responsible for specified 10
24	24		violations; amending s. 624.490, F.S.; providing a 11
25	25		penalty for failure to register as pharmacy benefit 12
26	26		managers under certain circumstances; providing an 13
27	27		effective date. 14
28	28		15
29	29		Be It Enacted by the Legislature of t he State of Florida: 16
30	30		17
31	31		Section 1. Section 465.1885, Florida Statutes, is 18
32	32		transferred, renumbered as section 624.491, Florida Statutes, 19
33	33		and amended to read: 20
34	34		624.491 465.1885 Pharmacy audits; rights.— 21
35	35		(1) A health insurer or health maintenance organiz ation 22
36	36		providing pharmacy benefits through a major medical individual 23
37	37		or group health insurance policy or a health maintenance 24
38	38		contract, respectively, must comply with the requirements of 25
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	40	+	HB 357 2022
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47	47		F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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51	51		this section when the health insurer or health maintenance 26
52	52		organization or any person or entity acting on behalf of the 27
53	53		health insurer or health maintenance organization, including, 28
54	54		but not limited to, a pharmacy benefit manager as defined in s. 29
55	55		624.490(1), audits the records of a pharmacy licensed under 30
56	56		chapter 465. The person or entity conducting such audit must If 31
57	57		an audit of the records of a pharmacy licensed under this 32
58	58		chapter is conducted directly or indirectly by a managed care 33
59	59		company, an insurance company, a third -party payor, a pharmacy 34
60	60		benefit manager, or an entit y that represents responsible 35
61	61		parties such as companies or groups, referred to as an "entity" 36
62	62		in this section, the pharmacy has the following rights : 37
63	63		(a) Except as provided in subsection (3), notify the 38
64	64		pharmacy To be notified at least 7 calendar days be fore the 39
65	65		initial onsite audit for each audit cycle. 40
66	66		(b) Not schedule an To have the onsite audit during 41
67	67		scheduled after the first 3 calendar days of a month unless the 42
68	68		pharmacist consents otherwise. 43
69	69		(c) Limit the duration of To have the audit period limited 44
70	70		to 24 months after the date a claim is submitted to or 45
71	71		adjudicated by the entity. 46
72	72		(d) In the case of To have an audit that requires clinical 47
73	73		or professional judgment , conduct the audit in consultation 48
74	74		with, or allow the audit to be conducted by, or in consultation 49
75	75		with a pharmacist. 50
76		-	~~ENROLLED~~
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84	84		F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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88	88		(e) Allow the pharmacy to use the written and verifiable 51
89	89		records of a hospital, physician, or other authorized 52
90	90		practitioner, which are transmitted by any means of 53
91	91		communication, to validate the pharmacy records in acco rdance 54
92	92		with state and federal law. 55
93	93		(f) Reimburse the pharmacy To be reimbursed for a claim 56
94	94		that was retroactively denied for a clerical error, 57
95	95		typographical error, scrivener's error, or computer error if the 58
96	96		prescription was properly and correctly dispen sed, unless a 59
97	97		pattern of such errors exists, fraudulent billing is alleged, or 60
98	98		the error results in actual financial loss to the entity. 61
99	99		(g) Provide the pharmacy with a copy of To receive the 62
100	100		preliminary audit report within 120 days after the conclusion of 63
101	101		the audit. 64
102	102		(h) Allow the pharmacy to produce documentation to address 65
103	103		a discrepancy or audit finding within 10 business days after the 66
104	104		preliminary audit report is delivered to the pharmacy. 67
105	105		(i) Provide the pharmacy with a copy of To receive the 68
106	106		final audit report within 6 months after the pharmacy's receipt 69
107	107		of receiving the preliminary audit report. 70
108	108		(j) Calculate any To have recoupment or penalties based on 71
109	109		actual overpayments and not according to the accounting practice 72
110	110		of extrapolation. 73
111	111		(2) The rights contained in This section does do not apply 74
112	112		to: 75
113		-	~~ENROLLED~~
114		-	HB 357 2022 ~~Legislature~~
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121	121		F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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125	125		(a) Audits in which suspected fraudulent activity or other 76
126	126		intentional or willful misrepresentation is evidenced by a 77
127	127		physical review, review of claims data or statements, or other 78
128	128		investigative methods; 79
129	129		(b) Audits of claims paid for by federally funded 80
130	130		programs; or 81
131	131		(c) Concurrent reviews or desk audits that occur within 3 82
132	132		business days after of transmission of a claim and where no 83
133	133		chargeback or recoupment is demanded. 84
134	134		(3) An entity that audits a pharmacy located within a 85
135	135		Health Care Fraud Prevention and Enforcement Action Team (HEAT) 86
136	136		Task Force area designated by the United States Department of 87
137	137		Health and Human Services and the United States Department of 88
138	138		Justice may dispense with the notice re quirements of paragraph 89
139	139		(1)(a) if such pharmacy has been a member of a credentialed 90
140	140		provider network for less than 12 months. 91
141	141		(4) Pursuant to s. 408.7057, and after receipt of the 92
142	142		final audit report issued under paragraph (1)(i), a pharmacy may 93
143	143		appeal the findings of the final audit report as to whether a 94
144	144		claim payment is due and as to the amount of a claim payment. 95
145	145		(5) A health insurer or health maintenance organization 96
146	146		that, under terms of a contract, transfers to a pharmacy benefit 97
147	147		manager the obligation to pay a pharmacy licensed under chapter 98
148	148		465 for any pharmacy benefit claims arising from services 99
149	149		provided to or for the benefit of an insured or subscriber 100
150		-	~~ENROLLED~~
151		-	HB 357 2022 ~~Legislature~~
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158	158		F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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162	162		remains responsible for a violation of this section. 101
163	163		Section 2. Subsection (6) of section 624.490, Florida 102
164	164		Statutes, is renumbered as subsection (7), and a new subsection 103
165	165		(6) is added to that section, to read: 104
166	166		624.490 Registration of pharmacy benefit managers. — 105
167	167		(6) A person who fails to register with the office while 106
168	168		operating as a pharmac y benefit manager is subject to a fine of 107
169	169		$10,000 for each violation. 108
170	170		Section 3. This act shall take effect July 1, 2022. 109