Fill out the form below or call us at (800) 345-4125.
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.
As Seen On
.avif)
Former Government Regulators on Your Side – Our team of healthcare defense specialists is spearheaded by former federal and state prosecutors who understand how the government and its contractors use data mining and proprietary algorithms to identify potential Fraud, Waste & Abuse (FWA) for audits and investigation. Because we understand how the government builds cases, we use their playbook to beat them.
Healthcare Specialty Attorneys and Consultants – Health Law Alliance specializes in healthcare law and is dedicated to defending providers and their licenses from overreach. Our founding partner previously served as a top executive for the biggest companies in healthcare, including McKesson, Relay Health, CoverMyMeds, United Health Group, Optum, and United Healthcare. We know the tricks insurance companies use to deny claims, and use that inside information against them.
Proven Track Record – Some clients turn to us when stakes are the highest, when their businesses are threatened, when their license is challenged, and when their options are limited. Our wins against the government and insurance companies can be reviewed HERE. Many more clients, however, turn to us at the first sign of potential trouble, when we can neutralize the problem before it grows. Either way, we have your back from beginning to end.
Frequently Asked Questions for PBM Audits
What exactly does a PBM audit look for, and how can it impact my pharmacy?
A PBM audit examines how your pharmacy handles prescriptions, billing, and inventory to ensure everything aligns with the PBM’s rules. Auditors check for compliance and, in some cases, errors or discrepancies that might lead to repayment demands, also known as recoupments. Beyond financial losses, a serious audit finding can even lead to network termination. Our team helps you understand what auditors are looking for and guides you in reducing any vulnerabilities before they escalate.
What documents do I need to have ready for a PBM audit?
You’ll typically need to provide clear and organized prescription records, billing and claims information, inventory tracking, and, if required, patient consent documentation. Having these records in order not only speeds up the audit but also shows auditors that your pharmacy operates transparently and compliantly. We can review your records ahead of time to spot any gaps that could trigger red flags.
How can Health Law Alliance help me handle a PBM audit?
We’re here to support you every step of the way. We’ll review your documentation, guide you through the audit process, and work to resolve any issues that arise. If the audit reveals findings you believe are inaccurate, we can also represent you in disputes or appeals, pushing back on unwarranted recoupments or penalties. Our goal is to protect your pharmacy’s reputation, finances, and continued operation.
What are the main risks of a PBM audit for pharmacies like mine?
The risks can range from relatively minor adjustments to significant recoupments, where the PBM demands repayment. In some cases, unresolved issues can lead to suspension or termination from the PBM network. The best way to minimize these risks is to approach the audit proactively—having strong documentation and a clear response strategy. We provide the support and guidance needed to approach audits strategically, aiming to protect your pharmacy from worst-case outcomes.
If I disagree with the audit findings, can I appeal them?
Absolutely. If you feel the audit conclusions are unfair, there are steps you can take to challenge them. We help you evaluate the audit results and, if warranted, prepare an appeal to dispute inaccuracies or excessive recoupment demands. Having an experienced defense team on your side can make a significant difference in successfully contesting findings.
How can I make my pharmacy better prepared for future PBM audits?
Start by building a strong compliance foundation: conduct regular internal audits, train staff on documentation standards, and keep current with PBM and regulatory changes. We offer compliance consultations to help you identify any risk areas and improve your documentation practices, reducing audit stress and keeping your pharmacy well-prepared. This proactive approach can give you peace of mind and lower the chances of unexpected audit issues.
%402x.svg){kind=icon}