HLS 19RS-797 ORIGINAL
2019 Regular Session
HOUSE BILL NO. 538
BY REPRESENTATIVE LEBAS
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
PHARMACISTS: Provides relative to pharmacy record audits
1 AN ACT
2To amend and reenact R.S. 22:1856.1(B)(introductory paragraph), (2), (3), (7)(b), and (8),
3 (D)(1)(introductory paragraph) and (2)(introductory paragraph), and (F), to enact
4 R.S. 22:1856.1(D)(3), and to repeal R.S. 22:1856.1(G)(3) and (4), relative to
5 pharmacy record audits; to provide for applicability of laws relative to such audits;
6 to provide relative to procedures for such audits; to repeal provisions relative to
7 onsite audits; to provide relative to audits conducted by or in consultation with
8 licensed pharmacists; to provide limitations on recoupment of reimbursements paid
9 to pharmacists; and to provide for related matters.
10Be it enacted by the Legislature of Louisiana:
11 Section 1. R.S. 22:1856.1(B)(introductory paragraph), (2), (3), (7)(b), and (8),
12(D)(1)(introductory paragraph) and (2)(introductory paragraph), and (F) are hereby amended
13and reenacted and R.S. 22:1856.1(D)(3) is hereby enacted to read as follows:
14 ยง1856.1. Pharmacy record audits; recoupment; appeals
15 * * *
16 B. Notwithstanding any other provision of law to the contrary, when an
17 onsite audit of the records of a pharmacy is conducted by an entity, the audit shall
18 be conducted in accordance with the following criteria:
19 * * *
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HB NO. 538
1 (2) No entity shall conduct an on-site audit at a particular pharmacy more
2 than one time annually. However, the provisions of this Paragraph shall not apply
3 when an entity must return to a pharmacy to complete an audit already in progress,
4 or there is an identified history of errors, an identified activity which a reasonable
5 man would believe to be inappropriate, or illegal activity that the entity has brought
6 to the attention of the pharmacy owner or corporate headquarters of the pharmacy.
7 (3)(a) The entity or any vendor or subcontractor of the entity which conducts
8 the initial onsite audit shall give the pharmacy notice at least two weeks before
9 conducting the initial onsite audit for each audit cycle.
10 (b) If the audit, review, or investigation is initiated based on or involves
11 alleged fraud or willful misrepresentation, notice before the initial on-site audit is not
12 mandatory where it could impede the audit, review, or investigation.
13 * * *
14 (7)
15 * * *
16 (b) A pharmacy shall be allowed at least thirty days following receipt of the
17 preliminary audit report in which to initiate an appeal to address any discrepancy
18 found during an on-site audit, as provided in Subsection E of this Section.
19 * * *
20 (8) Any audit which involves clinical judgment of a pharmacy with its
21 principal place of business in this state shall be conducted by or in consultation with
22 a licensed pharmacist licensed in Louisiana.
23 * * *
24 D.(1) No pharmacy shall be subject to recoupment of any portion of the
25 reimbursement for the dispensed product of a prescription unless one or more of the
26 following has occurred at the point of adjudication:
27 * * *
28 (2) Recoupment of claims shall be based on the actual financial harm to the
29 entity, or on the actual overpayment or underpayment, at the point of adjudication.
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HB NO. 538
1 A finding of an overpayment that is the result of dispensing in excess of the benefit
2 design, as established by the plan sponsor, shall be calculated as the difference
3 between what was dispensed in accordance with the prescriber's orders and the
4 dispensing requirements as set forth by the benefit design. Calculations of
5 overpayments shall not include dispensing fees unless one or more of the following
6 conditions has been satisfied:
7 * * *
8 (3) If any entity determines that the processed or adjudicated claim of a
9 pharmacy qualifies for recoupment based upon the use of manufacturer coupon or
10 copay card, such recoupment shall come from the beneficiary of the reduction.
11 * * *
12 F. Unless otherwise provided for in the network agreement, pharmacies or
13 payors may seek mediation to resolve contractual disputes related to pricing or
14 on-site audits.
15 * * *
16 Section 2. R.S. 22:1856.1(G)(3) and (4) are hereby repealed in their entirety.
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)]
HB 538 Original 2019 Regular Session LeBas
Abstract: Provides relative to the audit of pharmacy records.
Present law provides the criteria for the auditing of pharmacy records including the protocol
for conducting an onsite audit and a prohibition against an audit taking place within the first
five days of a month.
Proposed law repeals the requirement for onsite audits as they relate to the auditing of
pharmacy records.
Present law requires any audit involving clinical judgment be conducted by or in
consultation with a pharmacist.
Proposed law changes present law to require that any audit of a pharmacy with its principle
place of business within this state be conducted by a pharmacist licensed in La.
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HB NO. 538
Present law provides that no pharmacy be subject to recoupment of any portion of the
reimbursement for the dispensed product of a prescription unless one or more conditions
occur.
Proposed law changes present law by requiring that the condition occur at the point of
adjudication.
Present law provides that recoupment of claims be based on the actual financial harm to the
entity, or on the actual overpayment or underpayment.
Proposed law changes present law by requiring that such financial harm exist at the point of
adjudication.
Proposed law provides that if any entity determines that the processed or adjudicated claim
of a pharmacy qualifies for recoupment based upon the use of a manufacturer coupon or
copay card, such recoupment shall come from the beneficiary of the reduction.
Present law provides that present law does not apply to any federally funded activity,
specifically preempted by law or rule or any audit conducted pursuant to the participation
of a pharmacy in the Louisiana Medicaid Program. Proposed law repeals present law.
(Amends R.S. 22:1856.1; Adds R.S. 22:1856.1(D)(3); Repeals 22:1856.1(G)(3) and (4))
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