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Prime is Auditing or Terminating You. Without the right legal defense, you may face significant penalties and network exclusion. At Health Law Alliance, our legal team has successfully defended hundreds of clients against PBM audits, Fraud, Waste & Abuse (FWA) investigations, and network terminations. We have prevailed against Prime and have proven strategies for the audit and appeal process. Contact Us now for help.
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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.
Prime PBM Audit Defense: Common Questions
What triggers a Prime Therapeutics audit?
Prime Therapeutics typically initiates audits based on patterns of unusual billing, high-cost claims, or outlier patterns that may suggest non-compliance. Audits typically arise from data mining or other forms of targeting. If you’ve received a notice of audit, it’s crucial to understand what specific areas Prime intends to scrutinize. Working with an experienced PBM audit defense attorney can help you respond effectively and mitigate potential risks.
What penalties could my practice face in a Prime Therapeutics audit?
Prime audits can lead to a range of penalties, including repayment demands, fines, and potential termination from the PBM network. Penalties often depend on the audit findings, such as perceived overbilling or documentation issues. Health Law Alliance works to minimize or eliminate these penalties by challenging questionable audit findings and providing the necessary documentation to defend your practice.
How can an attorney help me during a Prime Therapeutics audit?
A skilled attorney can help in several ways, from analyzing the audit’s scope to disputing unfavorable findings and negotiating with Prime on your behalf. Health Law Alliance has extensive experience with PBM audits, including Prime Therapeutics. Our legal team reviews your claims and records to ensure compliance, identifies weaknesses in Prime’s audit methodology, and develops a defense strategy to protect your revenue and reputation.
What should I do if I receive a notice of audit from Prime Therapeutics?
If you receive an audit notice, it’s important to act quickly but carefully. Start by reviewing the audit notification to understand Prime’s specific areas of focus and deadlines for response. Avoid providing any additional information until you’ve consulted with an attorney experienced in Prime PBM audits. Health Law Alliance can help you prepare a response, gather the necessary documentation, and communicate with Prime on your behalf.
How long does the Prime Therapeutics audit process typically take?
The timeline for a Prime audit can vary based on factors like the audit’s scope, your responsiveness, and Prime’s review process. While some audits may be resolved in a few months, others can take longer, especially if disputes arise over the findings. Health Law Alliance helps streamline this process by ensuring timely and accurate submissions and challenging any unwarranted findings, reducing the impact on your practice.
Can Health Law Alliance help me avoid future Prime Therapeutics audits?
While no provider can fully eliminate the risk of future audits, Health Law Alliance can help you strengthen compliance practices and reduce potential audit triggers. Our attorneys provide proactive guidance on Prime’s contract requirements, documentation standards, and common areas of non-compliance. This preventative approach can lower the chances of an audit and protect your practice from costly recoupments.
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