Bill Text: OR SB371 | 2013 | Regular Session | Introduced
Bill Title: Relating to audits of claims for reimbursement of costs of prescription drugs.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Failed) 2013-07-08 - In committee upon adjournment. [SB371 Detail]
Download: Oregon-2013-SB371-Introduced.html
77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 1619
Senate Bill 371
Sponsored by Senator BATES (Presession filed.)
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Imposes requirements related to audits by or on behalf of
pharmacy benefit managers of pharmacy claims for reimbursement of
cost of prescription drugs.
A BILL FOR AN ACT
Relating to audits of claims for reimbursement of costs of
prescription drugs.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Section 2 of this 2013 Act is added to and made
a part of the Insurance Code. + }
SECTION 2. { + (1) As used in this section:
(a)(A) 'Audit' means a review of the records of a pharmacy by
or on behalf of an entity that finances or reimburses the cost of
health care services or pharmaceutical products.
(B) 'Audit' does not include an investigative audit involving
fraud or willful misrepresentation.
(b) 'Entity' includes:
(A) A pharmacy benefit manager;
(B) A health benefit plan as defined in ORS 743.730;
(C) A state agency; or
(D) An entity that represents or is employed by one of the
entities described in subparagraphs (A) to (C) of this paragraph.
(c)(A) 'Pharmacy benefit manager' means a third party
administrator that:
(i) Processes claims for prescription drugs or provides retail
network management for pharmacies or pharmacists;
(ii) Makes payments for claims for prescription drugs to
pharmacies or pharmacists;
(iii) Contracts with pharmacies or pharmacists for the
procurement of prescription drugs; or
(iv) Negotiates rebates with prescription drug manufacturers
for drugs paid for or procured as described in this subparagraph.
(B) 'Pharmacy benefit manager' does not include an insurer that
performs a service described in subparagraph (A) of this
paragraph.
(2) An entity conducting an audit of a pharmacy:
(a) Must give at least two weeks' notice of an on-site audit;
(b) Must conduct the audit in consultation with a licensed
pharmacist or the State Board of Pharmacy if the audit involves
clinical or professional judgment;
(c) May not conduct an audit of a claim more than two years
after the earlier of the date the claim was submitted to the
entity for payment or the date the claim was adjudicated by the
entity;
(d) May not conduct the audit during the first seven days of
any month without the pharmacy's consent;
(e) Must use the same standards and procedures for all
pharmacies of a similar size and volume of business; and
(f) Must establish a written procedure for the appeal of a
preliminary or final audit report that may be further contested
by either party through mediation.
(3) An entity must make a finding of underpayment or
overpayment of a claim based on identified transactions and not
based on an estimate or projection of the number of claims or
amounts that were underpaid or overpaid.
(4) The entity may not:
(a) Include dispensing fees or interest in the amount of any
overpayment;
(b) Recoup costs associated with clerical or recordkeeping
errors without proof that a pharmacy intended to commit fraud or
unless the error results in financial harm to the entity or a
consumer; or
(c) Charge a pharmacy for a denied or disputed claim or impose
other penalties until the audit and the appeals process described
in subsection (2)(f) of this section are final.
(5) An entity that contracts with a third party to conduct
audits may not:
(a) Agree to pay the third party a commission or percentage of
the amount of overpayment determined or recovered; or
(b) Permit the third party to calculate overpayments or
penalties that are based on an estimate or projection of the
number of claims or amounts that were overpaid.
(6) Information obtained during an audit is confidential and an
entity may not disclose the information.
(7) For purposes of this section, a pharmacy may use the
following records to validate a claim for a filling or refilling
a prescription or making a change to a prescription:
(a) An electronic or physical copy of the prescription from the
health care provider that prescribed the drug; or
(b) Any prescription that complies with ORS chapter 689.
(8)(a) After conducting an audit, an entity must provide the
pharmacy that is the subject of the audit with a preliminary
report of the audit. The preliminary report must be received by
the pharmacy no later than 60 days after the date on which the
audit was completed.
(b) An entity shall provide a pharmacy receiving a preliminary
report under paragraph (a) of this subsection no less than 30
days after receiving the report to dispute the report and to
provide additional documentation in support of the claim.
(9) If an audit results in a dispute or denial of a claim, the
entity conducting the audit shall allow the pharmacy to resubmit
the claim using any commercially reasonable method as long as the
period of time that the claim may be submitted under the terms of
the health care plan has not expired.
(10) An entity must provide the pharmacy that is the subject of
the audit with a final report of the audit no later than 90 days
after the date of the preliminary report or the date the appeal
is concluded, whichever is earlier. The final report must include
a final accounting of all moneys to be recovered by the entity.
(11) The entity must provide a copy of the final report to the
policyholder or certificate holder. + }
SECTION 3. { + Section 2 of this 2013 Act applies to audits
conducted on or after the effective date of this 2013 Act. + }
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