Prime PBM Audit Defense Attorney

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Prime PBM Audit Defense Attorneys

Prime Therapeutics audits can result in steep recoupments, penalties, and potential disruption to your practice. With complex audit criteria and rigorous compliance standards, pharmacies and healthcare providers need experienced legal representation to protect their interests. Health Law Alliance specializes in defending providers against aggressive Prime Therapeutics audits. Our attorneys have a deep understanding of PBM audit processes and know how to safeguard your practice’s financial stability.

  • In-depth Audit Review: Comprehensive analysis of Prime’s audit scope and methodology to identify potential compliance issues and areas of dispute.
  • Focused Defense Strategy: Customized legal strategy designed to reduce or eliminate repayment demands, fines, and penalties.
  • PBM Specialization: Deep understanding of Prime’s contract terms, industry regulations, and relevant state and federal laws.
  • Claims Dispute Resolution: Aggressive negotiation on claim rejections and chargebacks, with a focus on preserving revenue.
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    Why Health Law Alliance?

    Our team is your best defense.

    Healthcare Specialty Attorneys and Consultants - Health Law Alliance specializes in healthcare law and is dedicated to defending healthcare providers and their licenses from overreach.

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    Proven Track Record - The attorneys at Health Law Alliance have a demonstrated track record of success against the most aggressive government regulators and industry behemoths.

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    FAQs

    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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    01

    Understanding Prime PBM Audit Defense

    Prime Therapeutics, one of the largest pharmacy benefit managers (PBMs) in the United States, regularly conducts audits of pharmacies and healthcare providers. These audits aim to identify billing errors, non-compliance with Prime’s policies, and potential fraud. However, even minor documentation issues can lead to significant recoupments and penalties, making these audits challenging for providers to navigate alone.

    At Health Law Alliance, we specialize in Prime PBM audit defense, helping pharmacies and healthcare providers protect their financial stability and ensure compliance. Our experienced attorneys work to minimize financial losses and safeguard your practice’s reputation.

    02

    Key Laws and Regulations in Prime PBM Audits

    Prime PBM audits are governed by a complex web of federal and state regulations, as well as Prime Therapeutics’ specific contract terms. Key laws and regulations include:

    • The False Claims Act – Prevents fraudulent claims to government programs, which can be implicated in audits if billing issues are discovered.
    • Medicare and Medicaid Compliance – For providers servicing government-insured patients, strict adherence to federal billing guidelines is essential.
    • Prime PBM Contract Terms – Prime Therapeutics sets unique terms that providers must follow, covering areas such as prescription verification, record-keeping, and billing practices.

    Understanding these laws and guidelines is essential for an effective defense. Health Law Alliance’s attorneys have a deep knowledge of these regulations and use it to defend clients during Prime audits.

    03

    Common Issues and Challenges in Prime PBM Audits

    Prime Therapeutics audits can present a number of challenges for pharmacies and healthcare providers. Common issues include:

    • Documentation Errors – Missing or incomplete records can trigger repayment demands.
    • Prescription Verification – Failure to meet Prime’s requirements for verifying prescriptions may lead to claim denials or recoupments.
    • Billing Discrepancies – Minor inconsistencies between billed amounts and actual costs can be flagged as overpayments.
    • Policy Violations – Non-compliance with Prime’s contract terms, whether intentional or accidental, can lead to significant penalties.
    • Repetitive Audits – Providers may face repeated audits if Prime finds persistent issues, increasing administrative burden and financial risk.

    These challenges make it crucial to have experienced legal representation. Health Law Alliance’s audit defense team is skilled at identifying areas of risk and mitigating the impact of these audits on your practice.

    04

    The Legal Process for Prime PBM Audit Defense

    Facing a Prime Therapeutics audit involves several critical steps, each requiring careful attention to detail:

    1. Initial Notice Review – Analyze the audit notice from Prime to identify the specific issues under review.
    2. Document Collection – Gather all required records, including prescription records, billing statements, and compliance documentation.
    3. Audit Response Preparation – Work with legal counsel to prepare a comprehensive and accurate response to Prime’s audit findings.
    4. Challenge and Dispute – Dispute any inaccurate or unreasonable audit findings, using supporting evidence and legal arguments.
    5. Negotiation – If penalties or recoupments are demanded, negotiate with Prime to reduce or eliminate financial obligations.
    6. Future Compliance Review – Assess and strengthen internal compliance processes to reduce the risk of future audits.

    This process can be time-consuming and stressful, which is why Health Law Alliance guides clients through each stage, ensuring their rights are protected and minimizing disruption to their operations.

    05

    Potential Consequences and Outcomes of a Prime PBM Audit

    Prime Therapeutics audits can result in significant consequences for pharmacies and healthcare providers, such as:

    • Recoupment Demands – Prime may demand repayment for alleged overpayments, which can add up to substantial amounts.
    • Fines and Penalties – Depending on the severity of the findings, fines may be imposed.
    • Network Termination – In serious cases, Prime may terminate a provider’s contract, impacting patient access and revenue.
    • Ongoing Audits – Providers found with compliance issues may face increased scrutiny in future audits.
    • Reputation Risk – Negative audit findings can damage a provider’s reputation, affecting relationships with patients and other payers.

    Understanding these potential outcomes highlights the importance of proactive defense. Health Law Alliance works to minimize these risks, fighting to protect your practice’s financial health and reputation.

    06

    How Our Firm Assists with Prime PBM Audit Matters

    Health Law Alliance offers comprehensive legal support for providers facing Prime Therapeutics audits, including:

    • Audit Response Strategy – We create a tailored defense strategy to address Prime’s specific audit criteria and minimize liability.
    • Document Review and Compliance Analysis – Our team meticulously reviews your records to ensure compliance with Prime’s contract terms and identify any areas of vulnerability.
    • Claim Dispute and Negotiation – We challenge any inaccurate audit findings and negotiate recoupment amounts to protect your revenue.
    • Future Risk Mitigation – Beyond defense, we advise clients on improving compliance practices to reduce the risk of future audits from Prime or other PBMs.

    By partnering with Health Law Alliance, you gain an advocate with in-depth knowledge of Prime PBM audits and the healthcare industry, ensuring you receive the best possible defense.

    government & commercial claims Auditors

    Payor & PBM Audit Companies

    PBM Audit Information

    The Role of Pharmacy Benefit Managers in Pharmacy Audits

    To design an effective PBM audit response strategy, providers must understand the chain of events both prior to the initiation of a PBM audit and afterwards. For example, Special Investigative Units (SIUs) are often the genesis of a pharmacy audit, and the presence or absence of "audit risk factors" is informative on potentially broader exposure beyond the claims under audit. Any decision to resolve an audit should be informed and result in a full and final settlement of all liability, but PBM audit settlements need to be structured carefully to achieve this goal.

    PBMs that Conduct the Most Pharmacy Audits


    CVS Caremark, OptumRx, and Express Scripts, control at least 80% of the market, making them the three biggest PBMs. Humana also ranks among the largest. In addition, these PBMs regulate access to networks for smaller competitors, such as ESI's partnership with Prime. Plan sponsors, such as United Health, Cigna and Aetna, are vertically integrated with these PBMs, increasing audit risk for pharmacies because network sanctions are more likely to affect a significant aspect of a pharmacy's business across both government and commercial claims.

    Common Pharmacy Audit Areas


    PBMs and payors use artificial intelligence and data mining across medical and pharmacy claims to identify areas of potential inquiry. Among other areas, these inquiries typically involve high-reimbursing medicines, brand/generic substitution, inventory discrepancies, co-payment collection, prior authorization, and telehealth relations. Separately, DEA conducts audits and inspections for compliance to controlled substance regulations.  

    Types of Pharmacy Audits


    Common types of PBM audits include desk audits; on-site audits; invoice audits; and prescription audits. Irrespective of the type of PBM audit, all interactions with PBMs should be taken extremely seriously and can lead to severe consequences if not handled appropriately. For example, there has been a sharp increase in the federal prosecution of pharmacists for audit-related conduct, including answering PBM questions incorrectly. Accordingly, pharmacies should consider using outside audit counsel to avoid these pitfalls.

    Preparing for Pharmacy Audits


    Pharmacies can take various steps to prepare to meet PBM audits, including routine self-audits. In fact, the government publishes comprehensive guidance and a checklist to assist pharmacies in their audit planning, including self-audits around prescribing practices, controlled substance management, invoice management, and billing practices. If you need assistance designing or implementing an audit protection plan, please do not hesitate to contact us.

    Defending Pharmacy Audits


    Defending against a PBM audit requires comprehensive knowledge of the rights, responsibilities, and intricacies of pharmacies and their laws and regulations.  If your pharmacy has been identified for a PBM audit, there are a number of potential defenses available to you. The first defense against a PBM audit is to be proactive, and audit planning can lessen the chance of unfavorable findings. That said, it is often necessary to involve an attorney to hold PBMs to their obligations under law and provider agreements. For this reason, national audit services and pharmacy audit consultants are often ineffective.

    Pharmacy Audit Appeals


    Audit discrepancies and findings can be appealed based on the specific procedures outlined in the provider manuals. It is important to follow these requirements exactly, within the timeframes established, or your appeal rights could be lost and further review denied. In an appeal, it is critically important to make a complete record of why the audit findings or sanctions should be reversed, including through documentation, legal arguments, and corrective actions, if any. Depending on the outcome of the appeal, you may have further legal recourse against the PBM.

    Potential Consequences of Pharmacy Audits

    PBM audits can have severe repercussions depending on the results of the pharmacy audit, including recoupments, network sanctions, and criminal, civil and administrative investigations involving jail time, significant fines, and license revocation or exclusion. We publish a 10-part PBM Audit Guide that discusses the overlap between PBM audits and government investigations and how to successfully manage audit risk. This resource is complimentary to subscribers HERE.