| Last Action | 02/10/20: to Banking & Insurance (H) |
|---|---|
| Title | AN ACT relating to pharmacy audits. |
| Bill Documents | Introduced |
| Bill Request Number | 35 |
| Sponsors | S. Sheldon, D. Bentley, K. Banta, J. Blanton, A. Bowling, R. Brenda, R. Bridges, D. Frazier, C. Freeland, C. Fugate, R. Goforth, S. Heavrin, R. Huff, T. Huff, M. Koch, D. Lewis, S. Lewis, B. McCool, M. Meredith, J. Nemes, P. Pratt, B. Reed, S. Riley, S. Rudy, S. Santoro, N. Tate, W. Thomas, R. Webber, L. Yates |
| Summary of Original Version | Amend KRS 304.17A-740 to insert and amend definitions; provide exceptions to pharmacy audit laws; require Cabinet for Health and Family Services to take any steps necessary to effectuate legislation; amend KRS 304.17A-741 to require auditing entities to provide at least 90 days' notice for on-site audits; require that notices provide detailed information about each claim being audited; require that audits involving clinical or professional judgment be conducted in consultation with Kentucky-licensed pharmacists; require that audits involving compounded medication be conducted in consultation with Kentucky-licensed pharmacists trained to compound in compliance with state and federal law and regulations; establish information that may be requested by an auditing entity from a pharmacy; provide that certain information shall not be requested, obtained, or used during an audit; prohibit auditing entities from seeking a recoupment or refund in certain circumstances; require that a preliminary audit report be delivered to a pharmacy within 90 days after the conclusion of a desk audit; prohibit auditing entities from charging a pharmacy any fees for or relating to an audit; provide for how appeals shall be conducted; establish a safe harbor for an auditing entity's confirmation of a pharmacy's receipt of notice or a request; amend KRS 304.17A-743 to require auditing entities to establish an external appeals process for pharmacy audits; require external appeals for audits other than those conducted by or on behalf of a managed care organization providing services under KRS Chapter 205 to be conducted by an independent review entity certified by the Department of Insurance; require external appeals for audits conducted by or on behalf of a managed care organization providing services under KRS Chapter 205 to be conducted by an independent third party pursuant to administrative regulations promulgated by the Cabinet for Health and Family Services; establish notice requirements for external appeals; prohibit auditing entities from charging interest on disputed funds until all appeals are final; establish requirements for pharmacies requesting an appeal; establish procedures for external appeals of audits other than those conducted by or on behalf of a managed care organization providing services under KRS Chapter 205; establish information that shall be considered by an independent review entity or third party in making an external appeal determination; establish information upon which the independent review entity or third party shall base its external appeal determination; establish requirements for the external appeal determination; establish that determination of independent review entity shall be binding on the auditing entity; provide appeal to Cabinet for Health and Family Services for external appeal determinations of an independent third party; establish appeal procedures and requirements for appeal to Cabinet for Health and Family Services; establish penalties for auditing entities that fail to comply with a final determination issued in accordance with section; provide that an independent review entity or third party or any specialist the entity or third party utilizes shall not be liable for civil damages in certain circumstances; provide that appeals shall be confidential and not subject to the Open Records Act; amend KRS 304.17A-627 to establish conflict of interest requirements for external pharmacy audit appeals conducted by an independent review entity; establish reporting requirements for independent review entities conducting external pharmacy audit appeals; amend KRS 304.17A-633 to require reporting by the Department of Insurance and the Cabinet for Health and Family Services to the Interim Joint Committee on Banking and Insurance and to the Governor on external pharmacy audit appeals; amend KRS 304.17A-708, 304.17A-712, and 304.17A-714 to conform; create a new section of Subtitle 38A of KRS Chapter 304 to require limited health service organizations to comply with Sections 1, 2, and 3 of the Act; repeal KRS 304.17A-745 and 304.17A-747; provide that Act applies to provider agreements or contracts issued, delivered, entered, renewed, extended, or amended on or after the effective date of Act; provide that provisions of the Act shall be severable; EFFECTIVE January 1, 2021. |
| Index Headings of Original Version |
Effective Dates, Delayed - Pharmacy audits, requirements for, January 1, 2021 Federal Laws and Regulations - Federal law, pharmacy audit requirements, exemption for Insurance, Health - External appeals process, pharmacy audits, establishment of Insurance, Health - Pharmacy audits, requirements for Pharmacists - External appeals process, pharmacy audits, establishment of Pharmacists - Pharmacy audits, requirements for State Agencies - Cabinet for Health and Family Services, pharmacy audits by Medicaid MCOs State Agencies - Department of Insurance, pharmacy audit appeals State Employees - Pharmacy audits, state employee health plan, requirements for Medicaid - Pharmacy audits, Medicaid MCOs, requirements for Administrative Regulations and Proceedings - Cabinet for Health and Family Services, appeal of pharmacy audits by Medicaid MCOs Audits and Auditors - External appeals process, pharmacy audits, establishment of Audits and Auditors - Pharmacy audits, requirements for Reports Mandated - Cabinet for Health and Family Services, pharmacy audit appeals Reports Mandated - Department of Insurance, pharmacy audit appeals |
| 02/07/20 |
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| 02/10/20 |
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Last updated: 10/27/2020 12:10 PM (EDT)
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