Qlarant Audit Defense Attorneys

Former Top Prosecutors, Federal Investigators & Government Regulators Working for You

25+ Years of Experience

Qlarant Audit Defense Attorneys

Qlarant audits can have serious financial and operational implications for healthcare providers and pharmacies. Known for their thorough and often aggressive audit processes, Qlarant audits frequently result in significant recoupment demands and penalties. In addition, Qlarant is particularly motivated because it often shares in any recovery by the government. Health Law Alliance specializes in defending providers against Qlarant audits, helping you respond effectively, reduce liability, and protect your reputation.

  • Comprehensive Audit Defense: Tailored strategies to address Qlarant’s specific audit procedures and minimize financial losses.
  • Document Review and Compliance Analysis: Detailed assessment of your records to preemptively identify and resolve compliance issues.
  • Experienced Legal Representation: Attorneys with deep expertise in payor and government-related audits, standing up for your rights.
  • Claims Dispute and Negotiation: Aggressive defense against unwarranted audit findings and inflated recoupment demands.
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    Past Experience

    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.

    Tenacious Defense - Health Law Alliance has gone after – and beaten – much bigger opponents. When faced with a seemingly daunting legal issue, our attorneys are the ones to call.

    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

    Why is my practice being audited by Qlarant?

    Qlarant often conducts audits on behalf of government agencies and payors, including Medicare and Medicaid programs, to investigate potential fraud, waste, or abuse. If your practice is undergoing a Qlarant audit, it may be due to outlier billing patterns, high-cost claims, or other data-mining and targeting techniques. Health Law Alliance can help you understand the scope of the audit and prepare an effective defense to protect your practice.

    What risks does my practice face in a Qlarant audit or investigation?

    Qlarant audits can lead to significant financial consequences, including repayment demands, fines, and even exclusion from government-funded programs at later stages in the process. In addition, findings from a Qlarant audit can damage your practice’s reputation and disrupt operations. Health Law Alliance defends providers against these risks, aiming to minimize financial liabilities and prevent negative outcomes.

    How can Health Law Alliance assist me during a Qlarant audit?

    Our experienced attorneys guide you through every step of a Qlarant audit, from initial response to challenging findings and negotiating financial demands. We analyze your records, identify potential compliance gaps, and develop a strong defense strategy tailored to Qlarant’s audit standards. With Health Law Alliance on your side, you can protect your practice and mitigate audit-related risks.

    What should I do after receiving a Qlarant audit notice?

    If you receive an audit notice from Qlarant, it’s important to act promptly but carefully. Begin by reviewing the audit notification to understand the areas of focus and deadlines. Avoid providing additional information until you’ve consulted with an experienced attorney. Health Law Alliance can help you respond strategically, ensuring you meet Qlarant’s requirements without compromising your legal position.

    How long does the Qlarant audit process typically last?

    The length of a Qlarant audit can vary depending on the complexity of the issues involved, the audit’s scope, and your responsiveness. Some audits can be completed within a few months, while others may take longer if disputes arise. Health Law Alliance works to expedite the process, helping you address Qlarant’s concerns while protecting your practice’s interests.

    Can Health Law Alliance help prevent future Qlarant audits?

    While it’s impossible to completely prevent audits, Health Law Alliance offers proactive compliance support to reduce audit triggers. We help you strengthen internal processes, identify potential vulnerabilities, and implement best practices that align with Qlarant’s audit standards, which can help minimize the likelihood of future audits.

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    01

    Understanding Qlarant Audit Defense

    Qlarant conducts audits and investigations to detect fraud, waste, and abuse, particularly in government healthcare programs and PBM arrangements. These audits can be extensive, scrutinizing billing practices, prescription documentation, and compliance with state and federal regulations. Even minor errors can result in major financial liabilities. Health Law Alliance specializes in Qlarant PBM audit defense, helping providers navigate the complex audit process, protect their financial health, and maintain compliance.

    02

    Key Laws and Regulations in Qlarant Audits

    Qlarant audits operate under a strict framework of federal and state laws, along with the terms of specific payor and government contracts. Key regulations include:

    • False Claims Act (FCA) – This federal law is often relevant in Qlarant audits if there are allegations of fraudulent claims to government programs.
    • Medicare and Medicaid Compliance – For providers dealing with government-funded programs, compliance with federal billing standards is crucial.
    • Anti-Kickback Statute – Prevents improper financial incentives, which may be investigated in cases of suspected fraud.
    • Contractual Requirements – Qlarant’s audit criteria often reflect the specific terms of payor and government contracts, requiring detailed adherence to documentation and billing standards.

    Health Law Alliance’s legal team has a thorough understanding of these laws and uses this knowledge to protect clients during Qlarant audits.

    03

    Common Issues and Challenges in Qlarant Audits

    Providers facing Qlarant audits frequently encounter issues such as:

    • Documentation Deficiencies – Missing or incomplete records can trigger repayment demands.
    • High-Cost or High-Volume Claims – Qlarant scrutinizes high-cost or high-frequency claims, often leading to disputes.
    • Prescription Verification Standards – Strict requirements for verifying prescriptions can lead to challenges in demonstrating compliance.
    • Billing Discrepancies – Inconsistencies in billing can be flagged as overpayments, resulting in recoupment demands.
    • Potential for Criminal or Civil Penalties – Qlarant audits may uncover issues that lead to additional legal consequences, such as fines or exclusion from Medicare and Medicaid.

    Health Law Alliance’s attorneys specialize in navigating these challenges and reducing the impact of Qlarant’s findings on your practice.

    04

    The Legal Process for Qlarant Audit Defense

    The Qlarant audit defense process includes several essential steps:

    1. Reviewing the Audit Notice – Carefully analyze the audit notice to understand the issues under investigation.
    2. Gathering Documentation – Collect all necessary records, including billing statements, prescriptions, and compliance documentation.
    3. Developing a Response Strategy – Work with legal counsel to prepare a comprehensive response to Qlarant’s audit findings.
    4. Challenging and Disputing Findings – Dispute any unjust or inaccurate findings using evidence and legal arguments.
    5. Negotiation – If penalties or repayment demands arise, negotiate to minimize financial obligations.
    6. Strengthening Compliance – Evaluate internal processes to identify areas for improvement and reduce future audit risks.

    Health Law Alliance supports clients through each stage, helping to protect your rights and ensure the best possible outcome.

    05

    Potential Consequences and Outcomes of a Qlarant Audit

    A Qlarant audit can lead to a range of outcomes, including:

    • Recoupment Demands – Qlarant may request repayment for any identified overpayments.
    • Financial Penalties – Penalties may be imposed for non-compliance with Qlarant’s requirements.
    • Exclusion from Government Programs – Providers with serious findings may face exclusion from Medicare or Medicaid if government agencies get involved.
    • Heightened Audit Frequency – Practices found to be non-compliant may be subject to more frequent audits.
    • Reputation Risk – Negative findings can impact a provider’s reputation and relationships with other payers.

    Health Law Alliance’s legal team works to mitigate these consequences, advocating for a fair and favorable outcome for your practice.

    06

    How Our Firm Assists with Qlarant Audit Matters

    Health Law Alliance provides comprehensive legal support for providers facing Qlarant audits, including:

    • Audit Response and Defense Strategy – We develop a tailored response strategy that addresses Qlarant’s specific audit criteria.
    • Document Review and Compliance Support – Our team reviews your records in detail, identifying areas of vulnerability.
    • Claims Dispute and Financial Negotiation – We challenge any unreasonable findings and work to reduce financial liabilities.
    • Ongoing Compliance Assistance – Beyond audit defense, we advise clients on improving compliance practices to reduce the risk of future audits.

    Partnering with Health Law Alliance gives you a dedicated advocate with experience in Qlarant audits, ensuring you receive the strongest 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.