Legal Insights

We are proud to announce that the Health Law Alliance has successfully reversed a network termination from OptumRx for a Michigan-based independent pharmacy.

In 2025, wound care audits have become a top enforcement priority for federal and private payors, leaving providers unprepared and facing thousands in recoupments. Understanding how wound care audits progress is crucial to defending your practice from unjust penalties, and engaging counsel early is essential to protecting your practice. Learn how Health Law Alliance can help prepare a strategy-driven defense designed to minimize risk and preserve your practice’s reputation.

Earlier this year, the DOJ announced a settlement with Florida dermatology practices over allegations of false wound care claims submitted to Medicare. Learn more about the settlement and how Health Law Alliance can protect your wound care practice before regulators come knocking.

Medicare is intensifying scrutiny of wound care, OIG’s work plan spotlights skin-substitutes and related services, while CMS’s CERT program still finds sizable fee-for-service improper payments - so a targeted audit can escalate quickly to payment suspensions and referrals if mishandled.

Inventory reconciliation is one of the most scrutinized areas in PBM and payer audits and even small discrepancies can trigger major financial, reputational, and regulatory fallout.

PBM audits can quickly escalate from routine reviews into high-stakes enforcement actions with lasting financial, reputational, and regulatory consequences for pharmacies.

Health Law Alliance successfully overturned more than $30,000 in alleged inventory discrepancy findings asserted by Express Scripts’ Special Investigations Unit (SIU) against a Texas pharmacy.

New pharmacy owners face complex PBM audit requirements that demand strict documentation, accurate claims, and ongoing compliance. Establishing strong recordkeeping systems and proactive audit readiness can help prevent costly recoupments and protect long-term network participation.

PBM audits can leave pharmacies facing exaggerated findings, steep recoupments, and even network termination. With the right strategies and legal support, pharmacies can successfully challenge unfair results and protect their business.