PBM audits may result in collateral consequences, including licensing and disciplinary proceedings. In this case, HLA's experienced defense attorneys successfully convinced the State Board to decline further investigation, effectively resolving the matter at an early stage.

Our client, a Philadelphia pharmacy, was referred to the Prosecution Division of the Pennsylvania Department of State's Office of Chief Counsel following a PBM audit that noted violations. After the pharmacy retained HLA, the State declined to prosecute the case.

PBM audit

PBM Audits May Result in Referrals

We have written extensively about how PBM audits can lead to collateral consequences, including referral to state Medicaid agencies and Boards of Pharmacy. Accordingly, PBM audits need to be handled with extreme care, particularly when dealing with the larger PBMs or payors, most of whom cultivate close relationships with state and federal agencies.

In fact, PBM and payors often hire claims auditors and investigators from agencies such as the Department of Insurance or Medicaid Fraud Control Unit. In Pennsylvania, Keystone maintains particularly close relationships with federal and state agencies.

If you would like to read more about PBM audits and important considerations, please sign-up HERE for our complimentary, 10-part PBM Audit Guide.

HLA's Defense Strategy

Because our attorneys have worked as federal and state regulators, we understand the considerations at play. Overall, we use that insight to present our client's narrative in a convincing and compelling manner to assuage any regulatory concerns. In addition, it is always important to provide convincing evidence that the conduct at issue is isolated, and will not recur.

State Officials Declined to Prosecute

Based on our factual and legal arguments, the State declined to take further action and closed its file. We are grateful to the State for their consideration, as we strive to achieve successful outcomes as early in the process as possible. This approach is not only efficient for all involved, but spares the stress and anxiety involved in a drawn-out dispute.

With HLA's assistance, our client achieved a speedy and efficient final resolution, and can now refocus his energy where it should be, on running his business.

OTC Enforcement Update and PBM Audit Alert

On the heels of federal criminal investigations into OTC card usage, payors are now auditing OTC processes and imposing severe sanctions, including network termination, for non-compliance. Pharmacies should be wary of increased enforcement in this area and take steps to proactively reduce audit risk.


Medicare Advantage Cuts to Increase PBM Pressures

Insurers have bet big on Medicare Advantage, but the government is slowly cutting off that gravy train. Faced with rising medical loss ratios and CMS reimbursement cuts, payors and their PBMs are planning to make up those losses by increasing pharmacy claims audits and unilateral recoupments.


Pharmacy Alert: Texas Board of Pharmacy Investigations

Texas pharmacies are facing increasing scrutiny by the Board of Pharmacy, which is working closely with the DEA and other federal agencies, to investigate regulatory violations and Medicaid claims.


Safeguarding Independents: HLA Reverses PBM Termination on Appeal

PBMs are huge companies that often use their market power in an abusive and predatory manner. This case study and successful network appeal provides an example of why experienced PBM audit defense attorneys are necessary to hold PBMs legally accountable and protect your rights.