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: 23 624.3161Market 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: 43 624.490Registration 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: 50 624.491 465.1885Pharmacy 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, scriveners 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 pharmacys 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.