Florida Statutes
Part III - Authorization of Insurers and General Requirements (Ss. 624.401-624.491)
624.491 - Pharmacy audits.

(1) A health insurer or health maintenance organization providing pharmacy benefits through a major medical individual or group health insurance policy or a health maintenance contract, respectively, must comply with the requirements of this section when the health insurer or health maintenance organization or any person or entity acting on behalf of the health insurer or health maintenance organization, including, but not limited to, a pharmacy benefit manager as defined in s. 624.490(1), audits the records of a pharmacy licensed under chapter 465. The person or entity conducting such audit must:
(a) Except as provided in subsection (3), notify the pharmacy at least 7 calendar days before the initial onsite audit for each audit cycle.
(b) Not schedule an onsite audit during the first 3 calendar days of a month unless the pharmacist consents otherwise.
(c) Limit the duration of the audit period to 24 months after the date a claim is submitted to or adjudicated by the entity.
(d) In the case of an audit that requires clinical or professional judgment, conduct the audit in consultation with, or allow the audit to be conducted by, a pharmacist.
(e) Allow the pharmacy to use the written and verifiable records of a hospital, physician, or other authorized practitioner, which are transmitted by any means of communication, to validate the pharmacy records in accordance with state and federal law.
(f) Reimburse the pharmacy for a claim that was retroactively denied for a clerical error, typographical error, scrivener’s error, or computer error if the prescription was properly and correctly dispensed, unless a pattern of such errors exists, fraudulent billing is alleged, or the error results in actual financial loss to the entity.
(g) Provide the pharmacy with a copy of the preliminary audit report within 120 days after the conclusion of the audit.
(h) Allow the pharmacy to produce documentation to address a discrepancy or audit finding within 10 business days after the preliminary audit report is delivered to the pharmacy.
(i) Provide the pharmacy with a copy of the final audit report within 6 months after the pharmacy’s receipt of the preliminary audit report.
(j) Calculate any recoupment or penalties based on actual overpayments and not according to the accounting practice of extrapolation.

(2) This section does not apply to:
(a) Audits in which suspected fraudulent activity or other intentional or willful misrepresentation is evidenced by a physical review, review of claims data or statements, or other investigative methods;
(b) Audits of claims paid for by federally funded programs; or
(c) Concurrent reviews or desk audits that occur within 3 business days after transmission of a claim and where no chargeback or recoupment is demanded.

(3) An entity that audits a pharmacy located within a Health Care Fraud Prevention and Enforcement Action Team (HEAT) Task Force area designated by the United States Department of Health and Human Services and the United States Department of Justice may dispense with the notice requirements of paragraph (1)(a) if such pharmacy has been a member of a credentialed provider network for less than 12 months.
(4) Pursuant to s. 408.7057, and after receipt of the final audit report issued under paragraph (1)(i), a pharmacy may appeal the findings of the final audit report as to whether a claim payment is due and as to the amount of a claim payment.
(5) A health insurer or health maintenance organization that, under terms of a contract, transfers to a pharmacy benefit manager the obligation to pay a pharmacy licensed under chapter 465 for any pharmacy benefit claims arising from services provided to or for the benefit of an insured or subscriber remains responsible for a violation of this section.
History.—s. 1, ch. 2014-85; s. 1, ch. 2022-200.
Note.—Former s. 465.1885.

Structure Florida Statutes