Pharmacy benefit manager (“PBM”) audits can place a pharmacy’s network participation at serious risk, particularly when findings involve alleged inventory discrepancies, claims-processing issues, or documentation gaps. Health Law Alliance represented a New York pharmacy in connection with an Optum audit and successfully guided the pharmacy through the process, resulting in continued participation in Optum’s pharmacy network.

The audit findings at issue involved many alleged discrepancies, including inventory variances, untimely reversal of claims, and member-related documentation concerns. As is common in PBM audits, these findings did not reflect the full operational context of the pharmacy’s dispensing practices, inventory controls, and patient authorization procedures. Health Law Alliance worked closely with the pharmacy to rebut the audit findings through detailed factual explanations, supporting documentation, and a structured response. Moreover, the pharmacy’s submission to Optum also included legal arguments and outlined what heightened compliance measures the pharmacy was in the process of implementing, thereby demonstrating that the pharmacy’s operations were consistent with applicable contractual and regulatory requirements.  

Strategic Audit Response and Rebuttal of Findings

Health Law Alliance prepared and submitted a comprehensive audit response that directly addressed each category of alleged discrepancy. The response explained how inventory variances arose from factors common in pharmacy operations, clarified claims that were properly billed and dispensed, and corrected various findings that were unsupported by the pharmacy’s records. By grounding the response in documentary proof, counsel was able to present a clear and credible narrative demonstrating that the pharmacy acted in good faith and in compliance with PBM requirements.

This focused approach ensured that the audit review process remained tethered to objective evidence, allowing Optum to fully evaluate the pharmacy’s explanations and supporting materials.

Comprehensive Policies and Procedures to Ensure Future Compliance

In parallel with rebutting the audit findings, Health Law Alliance worked with the pharmacy to develop and implement a comprehensive set of updated policies and procedures. These materials addressed inventory management, billing accuracy, return-to-stock protocols, patient authorizations, proof-of-delivery requirements, staff training, and internal self-audits. The resulting compliance framework was tailored to Optum’s provider manual requirements and designed to prevent similar issues from arising in the future.

The implementation of these enhanced compliance measures, developed and executed under the guidance of experienced PBM attorneys, demonstrated the pharmacy’s commitment to operational integrity, regulatory compliance, and ongoing quality improvement. As a direct result of Health Law Alliance’s advocacy, Optum resolved the audit without imposing termination or other adverse action. Instead, Optum simply requested that the pharmacy implement an Immediate Corrective Action Required (“ICAR”).

With the support of counsel, the pharmacy fully satisfied Optum’s ICAR requirements and compliance expectations, resulting in continued, uninterrupted participation in Optum’s pharmacy network, with no further adverse actions and no additional audit demands arising from the matter.

Defending Pharmacies in PBM Audits and Network Reviews

This matter underscores the importance of early, strategic legal involvement when a pharmacy is facing a PBM audit or potential network termination. Health Law Alliance routinely represents pharmacies nationwide in PBM audits and other PBM compliance matters, helping pharmacies respond effectively, protect their network status, and implement sustainable compliance solutions.

For pharmacies confronting adverse audit findings or payer scrutiny, a well-crafted legal response combined with robust policies and procedures can be the key to preserving business continuity and long-term viability.

How Health Law Alliance Can Help

Our experienced healthcare defense attorneys understand how PBMs evaluate audit findings and compliance submissions, and we work closely with pharmacy owners to develop strategic responses, implement effective corrective measures, and preserve PBM network participation whenever possible.

If you are a pharmacy owner who has received adverse audit findings or a network termination notice, early legal involvement is critical. Contact Health Law Alliance today for a free consultation to discuss your options and learn how experienced healthcare defense counsel can help protect your pharmacy.

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