How S 413 changes current law

Compared against current U.S. Code AI-generated reading aid — verify against the official bill.

The bill prohibits retroactive reductions in payments on clean claims submitted by pharmacies under Medicare prescription drug plans.

• 42 U.S.C. 1395w-112(b)(4)(A)

  "(iv) Prohibiting retroactive reductions in payments on clean claims.--Each contract entered into with a PDP sponsor under this part with respect to a prescription drug plan offered by such sponsor shall provide that after the date of receipt of a clean claim submitted by a pharmacy, the PDP sponsor (or an agent of the PDP sponsor) may not retroactively reduce payment on such claim directly or indirectly through aggregated effective rate or otherwise except in the case such claim is found to not be a clean claim (such as in the case of a claim lacking required substantiating documentation) during the course of a routine audit as permitted pursuant to written agreement between the PDP sponsor (or such an agent) and such pharmacy. The previous sentence shall not prohibit any retroactive increase in payment to a pharmacy pursuant to a written agreement between a PDP sponsor (or an agent of such sponsor) and such pharmacy."

  This addition establishes a new requirement that prevents PDP sponsors from reducing payments on clean claims once they are submitted, enhancing payment security for pharmacies.