AB114,15,1211 (b) A pharmacy benefit manager may not require that a pharmacy or
12pharmacist enter into one contract in order to enter into another contract.
AB114,15,1613 (c) A pharmacy benefit manager shall notify a health benefit plan sponsor in
14writing of any activity, policy, or practice of the pharmacy benefit manager that
15presents a conflict of interest, directly or indirectly, with any requirement of this
16section.
AB114,15,19 17(4) Retroactive claim reduction. A pharmacy benefit manager may not
18retroactively deny or reduce a pharmacist's or pharmacy's claim after adjudication
19of the claim unless any of the following is true:
AB114,15,2020 (a) The original claim was submitted fraudulently.
AB114,15,2221 (b) The payment for the original claim was incorrect because the pharmacy or
22pharmacist had already been paid for the pharmacy services.
AB114,15,2323 (c) The pharmacy services were not rendered by the pharmacist or pharmacy.
AB114,16,2 24649.35 Audits of pharmacies or pharmacists. (1) Definition. In this
25section, “entity” means a defined network plan, as defined in s. 609.01 (1b), insurer,

13rd-party payer, or pharmacy benefit manager or a person acting on behalf of a
2defined network plan, insurer, 3rd-party payer, or pharmacy benefit manager.
AB114,16,4 3(2) Audit procedure requirements. An entity conducting an audit of
4pharmacist or pharmacy records shall do all of the following:
AB114,16,75 (a) If the audit is an audit on the premises of the pharmacist or pharmacy, notify
6the pharmacist or pharmacy in writing of the audit at least 2 weeks before conducting
7the audit.
AB114,16,98 (b) Refrain from auditing a pharmacist or pharmacy within the first 7 days of
9a month unless the pharmacist or pharmacy consents to an audit during that time.
AB114,16,1210 (c) If the audit involves clinical or professional judgement, conduct the audit
11by or in consultation with a pharmacist licensed in this state or the pharmacy
12examining board.
AB114,16,1413 (d) Limit the audit review to claims submitted no more than 2 years before the
14date of the audit.
AB114,16,1615 (e) Audit each pharmacist or pharmacy under the same standards and
16parameters as other similarly situated pharmacists or pharmacies.
AB114,16,1817 (f) Establish a written appeals process that allows appeals of preliminary and
18final reports and allows for mediation if either party is dissatisfied with the appeal.
AB114,16,2319 (g) Allow the pharmacist or pharmacy to use records of a hospital, physician,
20or other health care provider to validate the pharmacist's or pharmacy's records and
21use any prescription that complies with requirements of the pharmacy examining
22board to validate claims in connection with a prescription, refill of a prescription, or
23change in prescription.
AB114,16,25 24(3) Results of audit. (a) An entity that has conducted an audit of a pharmacist
25or pharmacy shall do all of the following:
AB114,17,2
11. Deliver to the pharmacist or pharmacy a preliminary report of the audit
2within 60 days after date of the conclusion of the audit.
AB114,17,53 2. Allow a pharmacist or pharmacy that is the subject of an audit at least 30
4days after the date the pharmacist or pharmacy receives the preliminary report to
5provide documentation to address any discrepancy found in the audit.
AB114,17,86 3. Deliver to the pharmacist or pharmacy a final audit report within 90 days of
7the date the pharmacist or pharmacy receives the preliminary report or the date of
8the final appeal of the audit, whichever is later.
AB114,17,119 4. Refrain from assessing a recoupment or other penalty on a pharmacist or
10pharmacy until the appeal process is exhausted and the final report under subd. 3.
11is delivered to the pharmacist or pharmacy.
AB114,17,1512 5. Base a finding of overpayment or underpayment of a claim on the actual
13overpayment or underpayment and not on a projection based on the number of
14patients served having a similar diagnosis or on the number of similar orders or
15refills for similar drugs.
AB114,17,1616 6. Exclude dispensing fees from calculations of overpayments.
AB114,17,1817 7. Refrain from using extrapolation in calculating the recoupments or penalties
18for an audit.
AB114,17,2019 8. Refrain from charging interest until the final report under subd. 3. has been
20delivered.
AB114,18,221 (b) If an audit of a pharmacist or pharmacy identifies a clerical or
22record-keeping error in a required document or record, the pharmacy benefit
23manager or entity conducting the audit may not request recoupment of funds from
24the pharmacist or pharmacy based on such an error unless the pharmacy benefit
25manager or entity proves the pharmacist or pharmacy intended to commit fraud or

1unless the error by the pharmacist or pharmacy results in actual financial harm to
2the pharmacy benefit manager, a health benefit plan, or a consumer.
AB114,18,63 (c) Information obtained in an audit under this section is confidential and may
4not be shared unless the information is required to be shared under state or federal
5law. An entity conducting an audit may have access to the previous audit reports on
6a particular pharmacy conducted by the same entity.
AB114,18,97 (d) Any entity that conducts an audit shall provide to the health benefit plan
8a copy of the final report of the audit and a disclosure of any recoupment amount
9assessed as a result of the audit.
AB114,18,12 10(5) Payment of auditors. A pharmacy benefit manager or entity conducting an
11audit may not pay an auditor employed by or contracted with the pharmacy benefit
12manager or entity based on a percentage of the amount recovered in an audit.
AB114,18,14 13(6) Applicability. This section does not apply to an investigative audit that is
14initiated as a result of a credible allegation of fraud or willful misrepresentation.