Health Insurance - Pharmacy Benefits Managers - Audits of Pharmacies and Pharmacists
Impact
The bill introduces various requirements and prohibitions that govern how PBMs can conduct audits. For instance, PBMs must provide a two-week notice before onsite audits, and they are limited to auditing a specific number of prescriptions unless they compensate the pharmacy for additional audits. The intent of these provisions is to reduce the administrative burden on pharmacists and ensure they are treated equitably in the audit process. Also, by restricting the use of extrapolation for calculating overpayments or underpayments, SB565 aims to minimize potential financial discrepancies that could arise from audits.
Summary
Senate Bill 565, titled 'Health Insurance - Pharmacy Benefits Managers - Audits of Pharmacies and Pharmacists,' aims to reform the auditing practices of pharmacy benefits managers (PBMs) regarding pharmacies and pharmacists in Maryland. This legislation extends the applicability of audit provisions to all PBMs, ensuring fair practices during audits related to claims submitted by pharmacies. One of the significant outcomes of the bill is the requirement for PBMs to conduct audits through registered auditing entities, which ensures compliance with state regulations and protects the interests of pharmacies against arbitrary auditing practices.
Conclusion
Overall, SB565 represents a pivotal step toward greater accountability in the health insurance sector, particularly regarding the relationship between pharmacies and pharmacy benefits managers. By instituting stricter audit protocols and ensuring fairness and transparency, the bill is poised to bolster the operational stability of pharmacies and, consequently, improve access to medication for patients.
Contention
Notably, the bill addresses the contentious issues surrounding the auditing practices of PBMs that have often been criticized for being overly aggressive and lacking transparency. Concerns had emerged regarding the financial impacts these audits could have on pharmacies, especially in the context of recouping payments without proper validation. By requiring PBMs to establish internal appeal processes for pharmacies to contest audit findings, SB565 seeks to provide an additional layer of protection and due process for pharmacies affected by audits.
Regulation of pharmacy benefit managers, fiduciary and disclosure requirements on pharmacy benefit managers, and application of prescription drug payments to health insurance cost-sharing requirements. (FE)
Regulation of pharmacy benefit managers, fiduciary and disclosure requirements on pharmacy benefit managers, and application of prescription drug payments to health insurance cost-sharing requirements. (FE)