Legal Insights

Independent pharmacies are heading into 2026 under tighter PBM oversight, more aggressive audit practices, and evolving reimbursement models driven by regulatory pressure and DIR fee reform. To survive in this environment, pharmacies must strengthen compliance, documentation, and inventory controls while partnering with experienced PBM counsel to manage audits, protect reimbursements, and avoid network termination.

Pharmacy benefit managers (PBMs) increasingly use data analytics and algorithmic surveillance to identify “red flag” prescriptions and atypical dispensing patterns, which can trigger audits, recoupments, network terminations, and payment withholds for independent pharmacies. By understanding common PBM risk indicators and implementing strong compliance practices, internal audits, documentation, and timely legal support, pharmacies can reduce exposure and more effectively defend themselves during PBM reviews and appeals.

We are proud to announce that the Health Law Alliance has successfully reversed a network termination from OptumRx for a Michigan-based independent pharmacy.

In 2025, wound care audits have become a top enforcement priority for federal and private payors, leaving providers unprepared and facing thousands in recoupments. Understanding how wound care audits progress is crucial to defending your practice from unjust penalties, and engaging counsel early is essential to protecting your practice. Learn how Health Law Alliance can help prepare a strategy-driven defense designed to minimize risk and preserve your practice’s reputation.

Earlier this year, the DOJ announced a settlement with Florida dermatology practices over allegations of false wound care claims submitted to Medicare. Learn more about the settlement and how Health Law Alliance can protect your wound care practice before regulators come knocking.

Medicare is intensifying scrutiny of wound care, OIG’s work plan spotlights skin-substitutes and related services, while CMS’s CERT program still finds sizable fee-for-service improper payments - so a targeted audit can escalate quickly to payment suspensions and referrals if mishandled.

Inventory reconciliation is one of the most scrutinized areas in PBM and payer audits and even small discrepancies can trigger major financial, reputational, and regulatory fallout.

PBM audits can quickly escalate from routine reviews into high-stakes enforcement actions with lasting financial, reputational, and regulatory consequences for pharmacies.

Health Law Alliance successfully overturned more than $30,000 in alleged inventory discrepancy findings asserted by Express Scripts’ Special Investigations Unit (SIU) against a Texas pharmacy.