PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
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…
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…
HLA Wins Dismissal of Criminal Charges After PBM Audit
Health Law Alliance has successfully challenged OptumRx's termination decisions for numerous pharmacies, ensuring they can continu…
State Board Declines Case Against HLA Client
PBM audits may result in collateral consequences, including licensing and disciplinary proceedings. In this case, HLA's experience…
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…
NYRx Transition May Increase Medicaid Program Risk
The transition of Medicaid pharmacy benefit to NYRx in New York brings increased dispensing fees but also heightened audit and enf…