Defense against CoventBridge UPIC audits, records requests, statistical extrapolation, and payment suspensions.
Request a Free Case ReviewCoventBridge Group is a Unified Program Integrity Contractor (UPIC) - a private contractor that conducts audits and investigations for CMS to identify suspected fraud, waste, and abuse across Medicare and Medicaid.
A CoventBridge matter can move through the full UPIC framework - records requests, unannounced site visits, beneficiary and prescriber interviews, postpayment review with statistical extrapolation, prepayment review, payment suspensions under 42 CFR 405.371, and referrals to HHS-OIG and DOJ. Health Law Alliance defends pharmacies, physicians, wound care providers, and DME suppliers nationwide against CoventBridge UPIC audits and investigations. Defense framework starts at the records request response.
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By the time the PBM sends the notice, the downstream exposure is already stacked. Here's what you're actually defending against.
Zepbound and other weight-loss-indicated GLP-1s claims routinely reimburse at $1,000 to $1,400 per fill. A 12-month look-back across 200 to 400 patients produces recoupment demands of $250K to $4M+. PBMs will also extrapolate findings across your full GLP-1 book.
OptumRx and Caremark are using GLP-1 audits as grounds for termination for cause. That designation follows you across every network and can end your Medicare Part D, Medicaid MCO, and commercial access - often within 30 days.
Compounded semaglutide and tirzepatide dispensing is a DEA / FDA / state board tripwire. A PBM finding can become a civil investigative demand, a state board complaint, or a federal healthcare fraud investigation within weeks.
Four factors make GLP-1 recoupments uniquely dangerous - and uniquely defensible, if you know where the PBM is actually vulnerable.
Brian O'Loughlin was a healthcare fraud investigator for Qlarant, CMS's largest Unified Program Integrity Contractor, where he oversaw the investigative pipeline: audits, document demands, investigative interviews, data mining and analytics, and statistical modeling. Whether it be Qlarant, or another UPIC like CoventBridge, Brian has the inside knowledge and experience necessary to neutralize these inquiries at an early stage, before risks grow.
Brian knows how to defend these cases because he used to build them for federal and state governments.
The first response is not a routine administrative task. It establishes the documents, timing, and record that the contractor can later use in its findings and any appeal.
Our bench includes former OptumRx senior leadership and a former prosecutor. We know the audit workflow because we wrote it. This is how we dismantle it.
Within 24 hours: parse every deadline in the audit notice, place a litigation hold on the claims at issue, and preserve adjudication logs before the PBM rotates them out.
Claim-by-claim reconstruction: prescriber PA rationale, plan criteria at time of fill, BMI/A1C/comorbidity support, step-therapy chain, and compounding regulatory posture. Every flagged script gets its own defense memo.
We draft and file the written appeal, quantify the PBM's extrapolation errors, and negotiate directly with the auditor and network relations - using relationships and playbooks from our time inside the PBM.
If the PBM refuses a reasonable resolution, we file in federal court and pair the suit with regulatory defense at DEA, FDA, and the state board - so a PBM dispute does not escalate into a license action.
Health Law Alliance handles the response and any parallel appeal, licensing matter or referral as one coordinated matter, so the strategy does not change hands as the matter moves between forums.
The bench includes a former Assistant U.S. Attorney nominated for the DOJ Director's Award, senior healthcare-company counsel, and attorney-providers with experience across healthcare audits and investigations.
Agency and company marks identify former professional experience of individual HLA team members. They do not imply affiliation, endorsement, or a client relationship.
If any of these describe your 2024 to 2026 GLP-1 dispensing activity, you are already in the audit pool - whether or not the notice has arrived.
Outcomes are summarized for confidentiality. Client names, precise geography, and identifying facts are redacted.
Recoupment Reversed
Multi-location independent pharmacy faced an OptumRx full-scope GLP-1 audit covering 2023 to 2025 semaglutide and tirzepatide claims. HLA reconstructed the PA chain for every flagged fill and documented extrapolation errors; final settlement reflected a 96% reduction.
Network Reinstated
Single-location pharmacy received a Caremark "termination for cause" tied to compounded semaglutide dispensing during the FDA shortage period. HLA's appeal brief led to full reinstatement across Caremark, SilverScript and Aetna networks without a recoupment.
State Board Closed
Compounding pharmacy was referred to the state board by an Express Scripts auditor alleging off-label tirzepatide dispensing. HLA's regulatory response demonstrated full compliance with USP 797 and FDA guidance in effect at the time; the board closed the matter with no discipline.
Attorney advertising. Prior results do not guarantee a similar outcome. Case summaries are generalized for confidentiality and are not a substitute for legal advice on your specific audit.
Seven questions that come up on almost every first call.
Before you write a single page of your written response, have a privileged conversation with attorneys who have overseen 2,000+ audits - from both sides of the table. Free, confidential, no retainer.