2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 175 - Insurance › Section 226 - Pharmacy Audits; Standards for the Conduct of Audits of Records; Appeals

Section 226. (a) For the purposes of this section, the term ''pharmacy benefit manager'' shall mean any person or entity that administers the (i) prescription drug, prescription device or pharmacist services or (ii) prescription drug and device and pharmacist services portion of a health benefit plan on behalf of plan sponsors, including, but not limited to, self-insured employers, insurance companies and labor unions. A health benefit plan that does not contract with a pharmacy benefit manager shall be considered a pharmacy benefit manager for the purposes of this section, unless specifically exempted.
(b) A pharmacy benefit manager shall conduct an audit of the records of a pharmacy in accordance with paragraphs (1) to (13), inclusive.
(1) The contract between a pharmacy and a pharmacy benefit manager shall identify and describe the audit procedures in detail.
(2) With the exception of an investigative fraud audit, the auditor shall give the pharmacy written notice at least 2 weeks prior to conducting the initial on-site audit for each audit cycle.
(3) A pharmacy benefit manager shall not audit claims beyond 2 years prior to the date of audit.
(4) The auditor shall not interfere with the delivery of pharmacist services to a patient and shall make a reasonable effort to minimize the inconvenience and disruption to the pharmacy operations during the audit process.
(5) Any audit that involves clinical or professional judgment shall be conducted by, or in consultation with, a licensed pharmacist from any state.
(6) A finding of an overpayment or underpayment shall be based on the actual overpayment or underpayment. A statistically sound calculation for overpayment or underpayment may be used to determine recoupment as part of a settlement as agreed to by the pharmacy.
(7) The auditor shall audit each pharmacy under the same standards and parameters with which they audit other similarly situated pharmacies.
(8) An audit shall not be initiated or scheduled during the first 5 calendar days of any month for any pharmacy that averages more than 600 prescriptions per week without the pharmacy's consent.
(9) A preliminary audit report shall be delivered to the pharmacy not later than 30 days after the conclusion of the audit.
(10) The preliminary audit report shall be signed and shall include the signature of any pharmacist participating in the audit.
(11) A pharmacy benefit manager shall not withhold payment to a pharmacy for reimbursement claims as a means to recoup money until after the final internal disposition of an audit, including the appeals process, as provided in subsection (c), unless fraud or misrepresentation is reasonably suspected or the discrepant amount exceeds $15,000.
(12) The auditor shall provide a copy of the final audit report to the pharmacy and plan sponsor within 30 days following the pharmacy's receipt of the signed preliminary audit report or the completion of the appeals process, as provided in subsection (c), whichever is later.
(13) No auditing company or agent shall receive payment based upon a percentage of the amount recovered or other financial incentive tied to the findings of the audit.
(c)(1) Each auditor shall establish an appeals process under which a pharmacy may appeal findings in a preliminary audit.
(2) To appeal a finding, a pharmacy may use the records of a hospital, physician, or other authorized prescriber to validate the record with respect to orders or refills of prescription drugs or devices.
(3) A pharmacy shall have 30 days to appeal any discrepancy found during the preliminary audit.
(4) The National Council for Prescription Drug Programs or any other recognized national industry standard shall be used to evaluate claims submission and product size disputes.
(5) If an audit results in the identification of any clerical or record-keeping errors in a required document or record, the pharmacy shall not be subject to recoupment of funds by the pharmacy benefit manager; provided, that the pharmacy may provide proof that the patient received the medication billed to the plan via patient signature logs or other acceptable methods, unless there is financial harm to the plan or errors that exceed the normal course of business.
(d) This section shall not apply to any audit or investigation of a pharmacy that involves potential fraud, willful misrepresentation or abuse, including, but not limited to, investigative audits or any other statutory or regulatory provision which authorizes investigations relating to insurance fraud.
(e) This section shall not apply to a public health care payer, as defined in section 1 of chapter 12C.
(f) The commissioner may promulgate regulations to enforce this section.