PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
The Performant Audit Playbook: How to Protect Your Practice from New York’s New Medicaid RAC
For years, New York healthcare providers have navigated the complex oversight of the Office of the Medicaid Inspector General (OMI…
PBM Enforcement Trends Independent Pharmacies Must Prepare for in 2026
Independent pharmacies are heading into 2026 under tighter PBM oversight, more aggressive audit practices, and evolving reimbursem…
PBM Audit Triggers: Understanding How Prescription Activity Is Evaluated
Pharmacy benefit managers (PBMs) increasingly use data analytics and algorithmic surveillance to identify “red flag” prescriptions…
Health Law Alliance Successfully Reverses OptumRx’s Network Termination for a Michigan Pharmacy
We are proud to announce that the Health Law Alliance has successfully reversed a network termination from OptumRx for a Michigan-…
Collateral Consequences of PBM Audits: What Pharmacies Need to Know
PBM audits can quickly escalate from routine reviews into high-stakes enforcement actions with lasting financial, reputational, an…
Victory for an Independent Pharmacy: Health Law Alliance Successfully Reverses Over $30,000 in PBM Inventory Discrepancy Findings
Health Law Alliance successfully overturned more than $30,000 in alleged inventory discrepancy findings asserted by Express Script…
When Inventory Discrepancies Become Audit Nightmares: Understanding One of the Most Common and Costly Audit Findings
Inventory reconciliation is one of the most scrutinized areas in PBM and payer audits and even small discrepancies can trigger maj…
Navigating PBM Audits: A Legal Guide for New Pharmacy Owners
New pharmacy owners face complex PBM audit requirements that demand strict documentation, accurate claims, and ongoing compliance.…
Top Red Flags That May Trigger a PBM Audit
PBM audits can be disruptive, costly, and often triggered by high prescription volumes, dispensing irregularities, or claim activi…