PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
Federal Prosecutors Decline Criminal Prosecution of HLA Client
Following a PBM audit that uncovered a $6.5 million billing discrepancy, federal prosecutors opened an investigation. After HLA wa…
MFCU Agrees Not to Charge HLA Client Following PBM Audit Referral
PBM audits must be handled correctly or severe consequences may result. In this case, HLA was able to persuade prosecutors not to…
DOJ Maintains Focus on Inventory Shortfalls
Department of Justice prosecutors continue to file numerous cases against pharmacies and their owners for inventory shortfalls and…
HHS-OIG Prioritizes 2024 Pharmacy Audits
Based on a recent announcement, the federal government (HHS-OIG) will be prioritizing audits of pharmacy claims in 2024. This furt…
HLA Wins Network Reinstatement for Illinois Pharmacy
PBMs are increasingly terminating pharmacies for minor infractions of the provider manuals or network enrollment forms. These term…
PBM Audit Response Summary
PBM audits can be resolved successfully, but more frequent and aggressive audits will require careful planning. Providers should a…
Audit-Related Prosecutions Rise Sharply
Federal prosecutors are now pursuing felony charges under Section 1035 for false statements in pharmacy audits, extending the risk…
When to Seek Help
Providers facing PBM audits must decide whether to rely on internal staff or seek audit counsel from experienced attorneys, partic…
OIG’s Self-Disclosure Protocol
Healthcare providers facing PBM audits can leverage the OIG's Self-Disclosure Protocol (SDP) to reduce liability by self-reporting…