Relating to procedures for certain audits of pharmacists and pharmacies.
By specifying that extrapolation cannot be used as a basis for calculations during audits, SB591 aims to protect pharmacists and pharmacies from potential financial penalties based on assumptions rather than actual evidence. This bill provides safeguards against unjust recoupments based on errors that do not cause any true financial harm. Additionally, the legislation mandates that health benefit plan issuers and pharmacy benefit managers must adhere to detailed audit protocols outlined in contracts with pharmacists and pharmacies, thereby promoting accountability within the auditing process.
Senate Bill 591 seeks to establish comprehensive procedures governing audits of pharmacists and pharmacies conducted by health benefit plan issuers and pharmacy benefit managers. The bill defines critical terms related to audit processes, such as 'desk audit', 'on-site audit', and 'extrapolation', to standardize how audits should be carried out. Importantly, it delineates clear rules regarding the notice required prior to an audit, along with strict limitations on the use of extrapolation during audit calculations, ensuring that audits are both fair and transparent.
One notable point of contention surrounding SB591 relates to its restriction on using extrapolation in audits, which some stakeholders argue could limit the ability of health benefit plan issuers to identify systematic issues across multiple claims. Opponents may express concern that this could potentially allow pharmacies to evade responsibility for broader patterns of non-compliance. However, supporters argue that limiting extrapolation fosters fairer audit practices and protects the rights of individual pharmacists and pharmacies against indiscriminate recoupment actions.
The overarching intention of SB591 is to enhance the auditing framework for pharmacists and pharmacies, ensuring that these processes are conducted with integrity and in compliance with applicable laws and regulations. The bill underscores the importance of balancing the need for effective cost control by health benefit plans while also ensuring that pharmacists and pharmacies are not subjected to undue risks during audits. Upon enactment, the measure is expected to contribute to a more equitable environment for audits within the Texas healthcare system.