The bill amends Section 5-19.1-35 of the General Laws concerning audits of pharmacies by insurers and their intermediaries. Key provisions include that a pharmacy shall not be subject to more than one on-site audit in connection with a carrier every twelve (12) months, unless there is an identified problem or fraud or misrepresentation is suspected. The bill also states that audits must be based on actual overpayments or underpayments rather than projections, and auditors cannot use extrapolation unless mandated by law. Pharmacies must receive a 14-day advance notice before an audit, which is limited to a maximum of 150 prescription claims and their refills. Additionally, the bill establishes a clear timeline for audit reports, allowing pharmacies to address discrepancies and ensuring that penalties cannot be assessed until the appeal process is completed.

Furthermore, the bill grants the Rhode Island attorney general the authority to enforce compliance with these audit regulations. It also clarifies that clerical errors related to Medicaid documentation do not constitute a willful violation without proof of intent to commit fraud. The act is set to take effect upon passage.

Statutes affected:
314: 5-19.1-35
314  SUB A: 5-19.1-35