Insurers and health plans would use actual overpayment amounts

Insurers and health plans would base overpayment findings on actual amounts. Auditors could project findings across claims to calculate repayments or penalties only when law or rules require it. These rules cover overpayment findings under the health insurer and health plan section and audit calculations for repayments or penalties. Findings cannot rely on counts of patients with similar diagnoses or similar drug orders or refills. State or federal law or rules must require the projection before auditors may use it to calculate repayments or penalties.

Insurers and health plans would have 12 months after paying a claim to start seeking repayment, unless a listed exception applies. This covers health insurers and plans seeking repayment for claims paid to health care providers. The deadline does not apply when a physical review, claims data, or statements indicate fraud, abuse, or other intentional misconduct. It also does not apply when a self-insured plan requires or requests recovery, or when a state or federal government plan requires it. The 12 months begin when the claim is paid. A recovery effort starts when the insurer or plan first identifies the payment error in an initial audit report or similar message delivered to the provider.

Companies that manage prescription benefits would give pharmacies written reasons when seeking repayment or charging them for a claim. This applies whenever a pharmacy benefit manager seeks repayment from a pharmacy or charges it for a claim. The notice must identify the error in processing or paying the claim and explain why the company seeks repayment or a charge.

Pharmacy audit rules would exclude investigative audits of pharmacy records when a listed misconduct test is met or the state conducts the audit. These exceptions concern investigative audits of pharmacy records. One exception applies when a physical review, claims data, or statements indicate fraud, waste, abuse, or other intentional misconduct. Another applies when other investigative methods indicate the pharmacy is or was engaged in criminal wrongdoing, fraud, or intentional or deliberate misrepresentation. The rules also do not apply when the state conducts the investigative audit.