Insights & Analysis
Practical guidance on PBM audits, federal investigations, compounding defense, DEA enforcement, telehealth compliance, and the regulatory pressures facing pharmacies and providers nationwide.
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PCAB Accreditation: Worth It or Not
PCAB accreditation verifies compounding process standards, not immunity from a PBM audit, an FDA inspection, or a state board comp…
PBM Audits of Compounded Prescription Claims
Compounded prescriptions are billed and audited ingredient by ingredient. What PBMs demand on ingredient pricing and documentation…
Proof of Delivery Requirements in a PBM Audit
PBM audits increasingly hinge on proof a prescription reached the patient. What counts as delivery documentation, and where the ga…
The Medicare ALJ Hearing: What to Expect
The Medicare ALJ hearing is the third level of appeals: qualifying thresholds, hearing format, witness testimony, the OMHA backlog…
Prior Authorization Documentation in PBM Audits
A PBM's own prior authorization approval does not close the file. When documentation questions surface in an audit, the burden oft…
Applied Behavior Analysis Medicaid Audits
OIG's multi-state ABA audit series found improper billing in nearly every sampled case. Supervision, session notes, and authorizat…
Texas Medicaid OIG Audits and Investigations
HHSC-OIG audits Texas Medicaid providers under Chapter 531, with payment holds and a SOAH appeal route that runs on strict, unforg…
Ambulance Medicare Audits: Medical Necessity and Destination
Repetitive non-emergent ambulance transport draws Medicare scrutiny on medical necessity, destination rules, and run-sheet documen…
Ophthalmic Compounding: Heightened Sterility Scrutiny
A 2013 endophthalmitis outbreak and a January 2026 FDA warning letter show why ophthalmic compounding faces close sterility scruti…