The state’s fair audit law includes requirements such as:
– The period covered by an audit may not exceed 2 years from the date the claim was submitted to or adjudicated
-A claim submitted to or adjudicated by a pharmacy benefits manager does not accrue interest during the audit period unless as required under AS 21.36.495
-PBM must give notice 14 days to the pharmacy before conducting an initial on-site audit
-PBM must not conduct: an audit in the first 7 days of a month unless agreed to by the pharmacy; more than one audit of a pharmacy within a 12-month period; or on site-audits of more than 250 separate prescriptions at one pharmacy within a 12-month period unless fraud by the pharmacy or pharmacy employee is alleged
– PBM must employ the services of a goodstanding, licensed pharmacist to conduct the audit or conduct the audit in consultation with a good standing, licensed pharmcist if the audit requires the clinical or professional judgment of a pharmacist;
-PBM must allow a pharmacy to use verifiable statment or records, including medication administration records of a nursing home, assisted living facility, hospital, physician, or other authorized practitioner, to validate the pharmacy records as well as a legal prescription to validate claims in connection with prescriptions, refills, or changes in prescriptions, including medication administration records, prescriptions sent by fax, electronic prescriptions, or documented telephone calls from the prescriber/ prescriber’s agent
-PBMs are prohibited from including the dispensing fee amount in a finding of an overpayment unless: a prescription was not actually dispensed; the prescriber denied authorization; the prescription dispensed was a medication error by pharmacy; or the identified overpayment is due solely on an extra dispensing fee
-PBM must audit each pharmacy and pharmacist under the same standards as other similarly situated pharmacies/ pharmacists audited by the PBM;
-PBM auditor is prohibited from: using extrapolation in calculating recoupments/penalties unless required by state or federal contracts; assessing a charge-back recoupment, or other penalty solely because a prescription is mailed or delivered at the requrest of a patient; or receiving payment based on a percentage of the amount recovered or for errors that have no financial harm to patient or medical plan
– PBM conducting an audit shall establish a written appeals process and may not assess a charge-back, recoupment, or other penalty until the appeals process has been exhausted and final report or settlement agreement is issued.

Link to Existing Law: HB 240b

This is a fairly substantive fair audit law, including language regarding limitations on overpayment amounts. It would be benefited to some degree if it included a statutory private right of action for an aggreived provider.