DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part of
the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute part of
the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
Pugh HB No. 62
Abstract: Provides for standards and requirements concerning pharmacy record audit
procedures, and for conditions under which recoupment of certain reimbursements to
pharmacies may occur.
Present law establishes standards and requirements for audits of pharmacy records by an "entity",
defined for purposes of present law as a managed care company or its representative, an
insurance company, or a third-party payor. Present law further provides for appeals and
recoupment procedures related to such audits of pharmacy records. Proposed law retains present
law.
Present law requires an entity, as defined in present law, which conducts an initial onsite audit of
a pharmacy to give the pharmacy notice at least two weeks before such audit for each audit cycle.
Proposed law adds requirement that if a vendor or subcontractor conducts an initial onsite audit
of a pharmacy on behalf of an entity, the vendor or subcontractor is subject to the same
requirement for providing notice to the pharmacy as is the entity.
Proposed law adds requirement for a vendor or subcontractor of an entity, if conducting a
pharmacy records audit on behalf of an entity, to identify to the pharmacy the entity on whose
behalf the audit is being conducted without necessity of this information being requested by the
pharmacy.
Proposed law adds requirement that a pharmacy records audit be based only on information
obtained by the entity conducting the audit and not based on any audit report or other information
gained from an audit conducted by a different auditing entity. Provides that nothing in proposed
law shall prohibit an auditing entity from using an earlier audit report prepared by that auditing
entity for the same pharmacy. Further provides that except as required by present law or federal
law, an entity conducting an audit may have access to a pharmacy's previous audit report only if
the previous report was prepared by that entity.
Proposed law stipulates that no pharmacy shall be subject to recoupment of any portion of the
reimbursement for the dispensed product of a prescription unless one or more of the following
has occurred:
(1)Fraudulent activity or other intentional and willful misrepresentation by the pharmacy as
evidenced by a review of claims data or statements, physical review, or any other
investigative method. (2)The pharmacy has engaged in dispensing in excess of the benefit design, as established by
the plan sponsor.
(3)The pharmacy has not filled prescriptions in accordance with the prescriber's order.
(4)Actual overpayment to the pharmacy.
(5)The pharmacy received reimbursement based on incorrect information it submitted on the
initial claim.
Proposed law makes technical changes to present law.
Effective upon signature of governor or lapse of time for gubernatorial action.
(Amends R.S. 22:1856.1(A), (B)(intro. para.) and (3)(a), (C)(3), (D), and (E); Adds R.S.
22:1856.1(B)(10) and (11))
Summary of Amendments Adopted by House
Committee Amendments Proposed by House Committee on Health and Welfare to the
original bill.
1. In the enumerated list of conditions that subject a pharmacy to potential recoupment
of reimbursement for the dispensed product of a prescription, added the condition of
the pharmacy receiving reimbursement based on incorrect information that it
submitted on the initial claim.
2. Made technical change.