Defense for pharmacies facing PBM on-site audits from OptumRx, Caremark, ESI, and Humana.
Request a Free Case ReviewA PBM on-site audit involves a PBM auditor visiting the pharmacy in person, typically with 5 to 15 business days advance notice. The pre-visit preparation, the on-site response posture, the management of the auditor's requests during the visit, and the immediate post-visit follow-up all shape the matter.
Pharmacies that treat the on-site audit as a passive event - "the auditor will tell us what they need when they arrive" - routinely produce material on-site that becomes the foundation of the recoupment calculation. Pharmacies that prepare with privileged counsel routinely close on-site audits with materially smaller findings. The defense framework starts the day the on-site audit notice arrives.
Anthony's background as a former federal prosecutor and executive for major healthcare companies provided a level of expertise and insight that made all the difference. His deep understanding of healthcare law, particularly in litigation and compliance matters, helped navigate complex legal issues with ease.
With upmost professional respect, I will be forever grateful to have such caring individuals as Attorney Anthony Mahajan and Attorney Diana Yastrovskaya who come into my life, even though I am a business owner but I always felt I was treated as a friend and was made reaching out to them with ease.
I had a great experience working with Health Law Alliance. From the very beginning, their team was incredibly helpful, responsive, and professional. They answered all of my questions quickly and kept me informed throughout the entire process.
Anthony and his staff have gone above and beyond. His proactive communication and ability to handle complex legal scenarios effectively have been a significant asset. Highly recommended attorney.
Top-notch attorneys with an unparalleled scope of experience and breadth of knowledge. You will want them in your corner.
Had nothing but great experience from them. Knowledgeable and professional in all aspects. They have a vast knowledge in health care cases, great to be on your side against insurances.
Trustworthy and experienced.
A PBM audit runs on the deadlines in your network agreement. What you produce, and when, becomes the record the PBM uses to set findings, chargebacks, and any network action.
Our bench includes a former federal prosecutor who served as Chief Compliance Officer of UnitedHealth Group, OptumRx’s parent company.
Within 24 hours: parse every deadline in the audit notice, place a litigation hold on the claims at issue, and preserve adjudication logs before the PBM rotates them out.
Claim-by-claim reconstruction: prescriber PA rationale, plan criteria at time of fill, BMI/A1C/comorbidity support, step-therapy chain, and compounding regulatory posture. Every flagged script gets its own defense memo.
We draft and file the written appeal, quantify the PBM's extrapolation errors, and negotiate directly with the auditor and network relations.
If the PBM refuses a reasonable resolution, we file in federal court and pair the suit with regulatory defense at DEA, FDA, and the state board - so a PBM dispute does not escalate into a license action.
Health Law Alliance handles the response and any parallel appeal, licensing matter or referral as one coordinated matter, so the strategy does not change hands as the matter moves between forums.
The bench includes a former Assistant U.S. Attorney nominated for the DOJ Director's Award, senior healthcare-company counsel, and attorney-providers with experience across healthcare audits and investigations.
Agency and company marks identify former professional experience of individual HLA team members. They do not imply affiliation, endorsement, or a client relationship.
Before you write a single page of your written response, have a privileged conversation with attorneys who have overseen 2,000+ audits - from both sides of the table. Free, confidential, no retainer.