Rhode Island General Laws Title 5. Businesses and Professions § 5-19.1-35. Audits

(1) A finding of overpayment or underpayment must be based on the actual overpayment or underpayment, and not a projection based on the number of patients served having a similar diagnosis, or on the number of similar orders or refills for similar drugs, unless the projected overpayment or denial is a part of a settlement agreed to by the pharmacy or pharmacist;

(2) The auditor may not use extrapolation in calculating recoupments or penalties unless required by state or federal laws or regulations;

(3) Any audit that involves clinical judgment must be conducted by, or in consultation with, a pharmacist; and

(4) Each entity conducting an audit shall establish an appeal process under which a pharmacy may appeal an unfavorable preliminary audit report to the entity.

(e)(1) A preliminary audit report must be delivered to the pharmacy or its corporate office within sixty (60) days after the conclusion of the audit. A pharmacy must be allowed at least thirty (30) days following receipt of the preliminary audit to provide documentation to address any discrepancy found in the audit. A final audit report must be delivered to the pharmacy or its corporate office within ninety (90) days after receipt of the preliminary audit report or final appeal, whichever is later. A charge-back recoupment or other penalty may not be assessed until the appeal process provided by the pharmacy benefits manager has been exhausted and the final report issued. If the identified discrepancy for a single audit exceeds twenty-five thousand dollars ($25,000), future payments in excess of that amount may be withheld pending the adjudication of an appeal. Auditors shall only have access to previous audit reports on a particular pharmacy conducted for the same entity.

(2) Auditors may initiate a desk audit prior to an on-site audit unless otherwise specified in the law.

(3) Contracted auditors cannot be paid based on the findings within an audit.

(4) Scanned images of all prescriptions including all scheduled controlled substances are allowed to be used by the pharmacist for an audit. Verbally received prescriptions must be accepted upon validation by the auditing entity and applicable for the initial desk or on-site audit.

(5) The period covered by an audit may not exceed two (2) years.

(6) Within five (5) business days of receiving the audit notification, pharmacies are allowed, at a minimum, one opportunity to reschedule with the auditor if the scheduled audit presents a scheduling conflict for the pharmacist.

(1)Exceptions. The provisions of this chapter do not apply to an investigative audit of pharmacy records when:

(2)Federal law. This chapter does not supersede any audit requirements established by federal law.