.png){kind=spacer}
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 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.
MORE ARTICLES BY CATEGORY
9th Circuit’s Landmark EKRA Ruling—What Providers Should Know
On July 11, 2025, the 9th Circuit upheld a laboratory operator’s convictions for violating EKRA by paying marketing agents to mislead providers into providing patient referrals for medically unnecessary blood tests. In this article, we analyze the 9th Circuit’s ruling and what it means for the future of EKRA enforcement.
Read More >>Collateral Consequences Mount Quickly After Adverse DEA Inspection
Adverse findings during a DEA inspection can trigger a chain reaction of serious consequences for pharmacies, including increasing fines, suspension or revocation of DEA registrations and pharmacy licenses, costly False Claims Act (FCA) lawsuits, and potential criminal liability.
Read More >>Heath Law Alliance Secures Reversal of a Medicaid Payment Suspension
Health Law Alliance successfully secured a full reversal of a Medi-Cal payment suspension for a California pharmacy, overturning speculative allegations made by the Department of Health Care Services. This case highlights the firm’s ability to protect healthcare providers against unjust enforcement actions and the critical value of experienced legal counsel in Medicaid and insurance disputes.
Read More >>Proposed HIPAA Security Rule Overhaul: What’s Changing - and Why Telehealth Providers Should Act Now
The proposed changes to the HIPAA Security Rule stand to have a significant impact on telehealth providers, as they aim to strengthen cybersecurity by making many previous guidelines mandatory and introducing new, more specific requirements. In this article, we outline seven key changes from the Proposed Rule and outline how providers can prepare their practices once the Rule is in effect.
Read More >>
