Pharmacy Benefit Manager (PBM) audits can threaten the stability of your pharmacy, impacting both your operations and finances. At Health Law Alliance, we specialize in defending pharmacies against aggressive PBM audit tactics, helping you avoid recoupments, network terminations, and other penalties. With experienced legal guidance, your pharmacy can navigate these audits with confidence, ensuring compliance while safeguarding your business.

Don't wait until your rights are lost. We often receive calls from pharmacies after they have been audited and terminated. The earlier we are involved, the better chance you have to prevent these severe consequences. Get us on your side today.

  • Comprehensive Audit Preparation: We review your practices to identify and resolve potential compliance risks before audits occur.
  • Effective Documentation Support: Ensure all necessary records meet PBM requirements, minimizing risk during audit evaluations.
  • Proactive Defense Strategies: Rely on a defense strategy tailored to protect against recoupment demands and unfounded allegations.
  • Ongoing Compliance Guidance: Stay informed about the latest PBM requirements and regulatory updates to prevent future audit issues.
  • Appeals and Legal Representation: Our team represents you throughout the audit process, including appeals and dispute resolution if necessary.
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    Attorneys

    Anthony Mahajan

    Anthony Mahajan, a seasoned leader with over two decades of crisis-management experience, specializes in federal and state government disputes. As a former, highly decorated federal prosecutor and top executive for major healthcare companies, he is recognized for his insightful approach in achieving successful resolutions within the complex healthcare system.

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    Diana Yastrovskaya

    Diana Yastrovskaya is a distinguished legal professional specializing in healthcare-related proceedings, for which she has been recognized as a "Rising Star." Fluent in Russian, she defends companies and individuals nationwide against government entities, with expertise in regulatory matters. Diana earned her Juris Doctor, magna cum laude, from the Benjamin N. Cardozo School of Law.

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    Madaline Tatro

    Madeline Tatro is a junior associate at Health Law Alliance, specializing in regulatory compliance and healthcare transactions. She previously advised healthcare companies on corporate compliance and fraud risks, including Stark Law and Anti-Kickback issues. Madeline holds a J.D. from Saint Louis University School of Law, with a focus in health law.

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    Craig Ismaili

    Craig Ismaili is an associate at Health Law Alliance, steering healthcare clients through regulatory disputes, appeals, and compliance snags. Previously, he fought coverage denials at a disability-rights group and advised on M&A and telehealth at a New Jersey firm. Craig holds a J.D. cum laude from Washington University and dual degrees from TCNJ. Away from work, he enjoys hockey, travel, reading, and time with his rescue dog, Jackie.

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    Recent Wins

    Win over Optum

    • PBM audit uncovered 25,000 unit discrepancy of Zegerid and other violations.
    • PBM referred "fraud" to Massachusetts Attorney General—Medicaid Fraud Control Unit (MFCU).
    • MFCU indicted Pharmacy & Owner on numerous criminal charges, including False Claims & Larceny.
    • After HLA was retained, State dropped all charges before trial and abandoned the prosecution.
    • Owner admitted no wrongdoing and was not excluded; Pharmacy avoided all network sanctions.

    Win over CVS

    • PBM audit uncovered $6.5 million inventory shortfall in compound cream APIs.
    • PBM referred "fraud" to U.S. Attorney's Office for the Eastern District of Pennsylvania, FBI, and HHS-OIG.
    • After HLA was retained, federal prosecutors declined to bring criminal charges against Owner.
    • Client settled case for $2.5 million, or less than 40% of the government's claimed loss on claims paid.
    • Owner admitted no wrongdoing, was not excluded, and suffered no licensing or other consequences.

    Win over ESI

    • PBM audit uncovered $600,000 inventory shortfall in brand and generic medications.
    • PBM referred "fraud" to Pennsylvania Attorney General—Medicaid Fraud Control Unit (MFCU).
    • MFCU opened grand jury investigation against Pharmacy and Owner for Medicaid Fraud and Theft.
    • After HLA was retained, State declined to bring criminal charges against Owner.
    • MFCU charged the Pharmacy, a corporate entity, instead.

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