Restricts audits of pharmacists conducted by insurers and their intermediaries, limiting audits to one per year unless fraud or misrepresentation is reasonably suspected. The RI attorney general has the authority to impose sanctions for violations.
If passed, this bill will directly amend Section 5-19.1-35 of the General Laws regarding Pharmacies. It outlines specific criteria that must be followed during audits, such as requiring prior notification to pharmacies, prohibiting the use of extrapolation in audit findings unless necessary, and mandating that any audit involving clinical judgment be conducted in consultation with a pharmacist. Moreover, the bill grants the Rhode Island Attorney General the authority to impose penalties for violations of these provisions, reinforcing the accountability of insurance companies and auditors in their audit practices.
Bill S0314 proposes significant changes to the regulations governing audits of pharmacies in Rhode Island. Specifically, it seeks to limit the number of audits that insurers and their intermediaries can conduct on pharmacies to a maximum of one per year, unless there is reasonable suspicion of fraud or other misrepresentation. The intent of the bill is to create a more fair and manageable auditing environment for pharmacists, ensuring that they are not subjected to excessive scrutiny and the potential for unjust penalties. This legislative effort stems from growing concerns over the burdens placed on pharmacies by frequent and often invasive audit practices.
One of the notable points of contention surrounding S0314 involves the balance between protecting pharmacies from excessive audits and the need for insurers to ensure compliance and prevent fraud. Proponents of the bill argue that the current auditing processes are overly rigorous and disproportionately harmful to pharmacies, especially small and independently-owned ones. Opponents, including some representatives from the insurance industry, might express concerns about the potential increase in fraudulent activities if audit oversight is relaxed. Overall, the discourse surrounding this bill underscores the ongoing tension between regulatory oversight and business operations within the healthcare sector.