Bill Summaries: H644 (2011-2012 Session)

  • Summary date: Jun 30 2011 - View summary

    AN ACT TO ESTABLISH PHARMACY AUDIT RIGHTS AND TO ESTABLISH STANDARDS FOR RECOUPMENT OF CLAIMS AND AUTHORIZING A THIRTY-DAY PERIOD TO SUBMIT A WRITTEN REQUEST FOR A RECONSIDERATION REVIEW TO THE DIVISION OF MEDICAL ASSISTANCE. Summarized in Daily Bulletin 4/5/11, 5/31/11, 6/2/11, and 6/15/11. Enacted June 27, 2011. Section 1 is effective January 1, 2012. The remainder is effective June 27, 2011.

  • Summary date: Jun 15 2011 - View summary

    Senate committee substitute makes the following changes to 3rd edition. Provides that pharmacy has the right to 14 (was, 21) days' notice of the initial on-site audit for each audit cycle. Provides that for audits conducted other than in response to an identified problem, the audit is limited to 100 (was, 40) selected prescriptions. Provides an exception to the one-audit-per-year limitation for cases where fraud or misrepresentation is reasonably suspected. Provides an exception to the provision that recoupments of disputed funds are to occur only after final internal disposition of an audit, including appeals, for cases where fraud or misrepresentation is reasonably suspected. Changes effective date of act's main provisions from October 1, 2011, to January 1, 2012.

  • Summary date: Jun 2 2011 - View summary

    House amendments make the following changes to 2nd edition. Amendment #1 amends proposed GS 90-85.50(b)(2) to clarify that a pharmacy has a right to have any audit that involves clinical (previously clinical and professional) judgment be done with a pharmacist as provided. Amends proposed GS 90-85.51(b) to limit the dismissal to only the unsubstantiated portion of the audit report without any further proceedings (previously could dismiss the entire audit report).
    Amendment # 2 amends proposed GS 90-85.50(b)(10) to clarify that a pharmacy has the right to, except in certain cases, be free of recoupments as provided, unless defined within the billing requirements set forth in the pharmacy provider manual not inconsistent with current North Carolina Board of Pharmacy Regulations.

  • Summary date: May 31 2011 - View summary

    House committee substitute makes the following changes to 1st edition.
    Amends proposed GS 90-85.50, specifying that a pharmacy has the right to at least 21 days advance notice (was, 30 days) of the initial on-site audit for each audit cycle. Clarifies that the pharmacy has the right to have any audit that involves clinical or professional judgment conducted with a pharmacist employed or working under contract with the auditing entity, and the right to have the auditing entity provide, upon request, all records related to the audit if required under the contract. Clarifies that the audit is limited to claims identified by prescription numbers if the audit is conducted for an identified problem; otherwise the audit is limited to 40 selected prescriptions (rather than 25 randomly selected prescriptions). States that the pharmacy will not be subject to the initiation or scheduling of audits during the first five (was, seven) calendar days of any month due to the high volume of prescriptions filled during that time, without express consent; requires the pharmacy to cooperate with the auditor to establish an alternate date if necessary. Clarifies that a final audit report must be delivered to the pharmacy within 90 days (was, six months) after the end of the specified appeals period. Amends proposed GS 90-85.51, clarifying that each entity conducting an audit must provide a copy of the audit findings after completion of the appeals process, if required by the contract. Makes other clarifying changes.
    Adds a section directing a provider to submit to the Division of Medical Assistance a written request for a Reconsideration Review within 30 days of receipt of notice of tentative decision. States that failure to request the Review in the specified time will result in the implementation of the tentative decision as the final decision. Specifies that any provider who received notice of a tentative decision on or after March 1, 2011, is eligible to resubmit a request for a Review within 30 working days of this act becoming law. Directs the Department of Health and Human Services to amend any rule in conflict with this provision. Makes this provision effective when it becomes law. Makes a conforming change to the title.

  • Summary date: Apr 5 2011 - View summary

    Enacts new Article 4C of GS Chapter 90 to specify rights of pharmacies in connection with audits of their records by managed care companies, insurance companies, third-party payers, and others responsible for payment of health care services. Rights include 30 days advance notice of an audit, a requirement that audits involving clinical or professional judgment be only by licensed North Carolina pharmacists, limitations on the scheduling and scope of the audits, rights to have access to records from prescribers to validate prescriptions, prohibitions against deeming certain kinds of discrepancies as fraudulent, and requirements for dismissal of audits under certain conditions. Requires establishment of an appeals process by the entity conducting the audit. Prohibits recoupment of disputed funds prior to final internal disposition of an audit including exhaustion of appeal rights, and restricts the amount of the recoupment. Effective October 1, 2011.