"New Jersey Pharmacy Audit Bill of Rights;" establishes procedures by which entities are required to conduct audits of pharmacies.
The bill sets clear limitations on the number of prescriptions audited and the frequency of audits, limiting entities to a maximum of 200 prescriptions per year and preventing the same entity from auditing the same pharmacy more than once every six months. Furthermore, it disallows the use of extrapolation for recoupment calculations, which could previously penalize pharmacies based on sampled data rather than actual audits. This change aims to protect pharmacies from unfair financial repercussions due to clerical errors and record-keeping mistakes by defining such errors as non-fraudulent unless they indicate willful misrepresentation.
Senate Bill S1008, titled the "New Jersey Pharmacy Audit Bill of Rights," aims to establish regulatory procedures governing pharmacy audits conducted by various entities such as insurance companies and pharmacy benefits managers. The bill mandates that auditing entities give pharmacies prior notice, specifically 14 days, along with a list of claims to be audited, thereby ensuring that pharmacies are adequately prepared. It also stipulates the processes for auditing, including the requirement that audits involving clinical judgment must be conducted by or under the supervision of a licensed pharmacist.
One of the notable points of contention involves the carve-out provisions relating to audits predicated on suspicions of fraud, which remain unregulated by this bill. Investigative audits, especially those currently conducted under the auspices of the Department of Human Services regarding Medicaid fraud and other potential abuses, are expressly excluded from this bill's protections. This exclusion raises concerns regarding the oversight and fairness of audits that could disproportionately affect vulnerable healthcare providers.
The bill empowers the Commissioner of Banking and Insurance to enforce these new regulations, with the authority to investigate complaints related to violations and to oversee the recoupment process. This level of oversight is designed to enhance accountability in the auditing process, aiming to balance the interests of pharmacies and the auditing entities while promoting a fair and transparent claims process.