Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 59 - Pharmacy Benefits Managers › Rule 191-59.4 - Audits of Pharmacies by Pharmacy Benefits Managers

Current through Register Vol. 47, No. 3, July 24, 2024
(1) An audit of
				pharmacy records by a pharmacy benefits manager shall be conducted in
				accordance with the following:
a. The pharmacy
				benefits manager conducting the initial on-site audit must provide the pharmacy
				written notice at least ten business days prior to conducting any
				audit;
b. Any audit which involves
				clinical or professional judgment must be conducted by or in consultation with
				a pharmacist;
c. When a pharmacy
				benefits manager alleges an error in reimbursement has been made to a pharmacy,
				the pharmacy benefits manager shall provide the pharmacy sufficient
				documentation to determine the specific claims included in the alleged
				error;
d. A pharmacy may use the
				records of a hospital, physician or other authorized practitioner of the
				healing arts for prescription drugs or medicinal supplies, written or
				transmitted by any means of communication, for purposes of validating the
				pharmacy record with respect to orders or refills of a drug dispensed pursuant
				to a prescription;
e. Each pharmacy
				shall be audited under the same standards and parameters as other similarly
				situated pharmacies audited by the pharmacy benefits manager;
f. The period covered by an audit may not
				exceed two years from the date on which the claim was submitted to or
				adjudicated by a managed care company, insurance company, third-party payor, or
				any pharmacy benefits manager that represents such entities;
g. Unless otherwise consented to by the
				pharmacy, an audit may not be initiated or scheduled during the first seven
				calendar days of any month due to the high volume of prescriptions filled
				during that time;
h. The
				preliminary audit report must be delivered to the pharmacy within 120 days
				after conclusion of the audit. A final written audit report shall be received
				by the pharmacy within six months of the preliminary audit report or final
				appeal, whichever is later;
i. A
				pharmacy shall be allowed at least 30 days following receipt of the preliminary
				audit report in which to produce documentation to address any discrepancy found
				during an audit; and
j. If it is
				determined by the pharmacy benefits manager that an error in reimbursement to a
				pharmacy occurred, the following criteria apply:
(1) For each contract between the pharmacy
				benefits manager and the pharmacy existing on or after January 1, 2015, a
				pharmacy's usual and customary price for compounded medications is considered
				the reimbursable cost, unless the contract between the pharmacy benefits
				manager and the pharmacy specifically provides details for a pricing
				methodology for compounded medications.
(2) A finding of error in reimbursement must
				be based on the actual error in reimbursement and not be based on a projection
				of the number of patients served having a similar diagnosis or on a projection
				of the number of similar orders or refills for similar prescription
				drugs.
(3) Calculations of errors
				in reimbursement must not include dispensing fees unless prescriptions were not
				actually dispensed, the prescriber denied authorizations, the prescriptions
				dispensed were medication errors by the pharmacy, or the amounts of the
				dispensing fees were incorrect.
(4)
				Any clerical or record-keeping error of the pharmacy, including but not limited
				to a typographical error, scrivener's error, or computer error, regarding a
				required document or record shall not be considered fraud by the pharmacy under
				paragraph 59.6(3)
"a"
or under a pharmacy's contract with the
				pharmacy benefits manager.
(5) In
				the case of an error that has no actual financial harm to the patient or
				third-party payor, the pharmacy benefits manager shall not assess a charge
				against the pharmacy.
(6) If a
				pharmacy has entered into a corrective action plan with a pharmacy benefits
				manager, and if the pharmacy fails to comply with the corrective action plan in
				a manner that results in overpayments being made by the pharmacy benefits
				manager to the pharmacy, the pharmacy benefits manager may recover the overpaid
				amounts. For purposes of this paragraph, "corrective action plan" means an
				agreement entered into by a pharmacy benefits manager and a pharmacy which is
				intended to promote accurate submission and payment of pharmacy
				claims.
(7) During the audit
				period, interest on any outstanding balance shall not accrue for the pharmacy
				benefits manager or the pharmacy. For purposes of this rule, the audit period
				begins with the notice of the audit and ends with a final determination of the
				audit report.