The bill amends Section 5-19.1-35 of the General Laws in Chapter 5-19.1 entitled "Pharmacies" to establish specific criteria for on-site audits of pharmacy records conducted by carriers or their intermediaries. It stipulates that overpayment or underpayment findings must be based on actual amounts rather than projections, prohibits the use of extrapolation in calculating recoupments or penalties unless mandated by law, requires clinical judgment audits to be conducted by or in consultation with a pharmacist, and mandates the establishment of an appeal process for pharmacies. The bill also sets forth requirements for audit notifications, limits the number of prescription claims and signature logs that can be examined, and outlines the timeline for delivering preliminary and final audit reports. It further states that clerical or typographical errors do not constitute willful violations subject to criminal penalties without proof of intent to commit fraud.

Additionally, the bill introduces new provisions, including limiting the frequency of audits to once every twelve months unless fraud is suspected, allowing the use of scanned prescription images for audits, and specifying that the period covered by an audit may not exceed two years. It also grants the Rhode Island attorney general the authority to impose fines, penalties, or other sanctions to ensure compliance with the section. The bill specifies that these changes would take effect upon passage and aims to restrict the number of audits on pharmacists to one per year unless there is a reasonable suspicion of fraud or misrepresentation.

Statutes affected:
5248: 5-19.1-35