You Have an Ally in Our Pharmacy Law Firm

When Civil Claims Arise - We Challenge Them

Business & Employment Litigation Attorneys for Healthcare Providers

Business and employment litigation can result in devastating consequences for healthcare providers, including financial losses, operational disruptions, and reputational damage. Your approach to these legal challenges is critical. Do not wait until your rights are lost.

Healthcare providers need to hold their business partners, employees, and adversaries accountable for their legal obligations and contractual agreements. Our attorneys have extensive experience handling complex business and employment litigation in the healthcare industry. No one understands the unique legal issues faced by healthcare providers better than us. Our nationally recognized team of business and employment litigation attorneys has decades of combined experience in the healthcare industry and legal field. Put our insider knowledge and expertise on your side today. If you are facing a business dispute or employment issue, act now.

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BUSINESS CASES HANDLED

175+
Past Experience
BUSINESS & EMPLOYMENT LITIGATION EXPERTISE

Pharmacy Audit Defense Lawyers

Our business and employment litigation team has helped healthcare clients avoid millions of dollars in losses, maintain their operations, protect their reputations, and defend against aggressive legal tactics.

We provide expert legal advice tailored to your specific circumstances using our knowledge of the healthcare industry's unique legal challenges and potential pitfalls.

As lawyers, we leverage federal and state law to protect your rights and interests. When your practice or livelihood is threatened, our team of healthcare business and employment litigation attorneys is your fiercest ally.

1200+

Clients served

2500+

matters handled

24/7

availability

100%

flexible rates
Our PBM audit defense team has helped clients avoid millions of dollars in recoupments, remain in-network, win reinstatement, and defend themselves against abusive PBM tactics.

When your license or livelihood is threatened, our team of pharmacy PBM audit attorneys is your fiercest ally.

1500+

Clients served

5000+

matters handled

24/7

availability

100%

flexible rates
"Anthony is the definition of a 'plug and play' athlete. Put him the game and he will change it."
- Former Acting U.S. Attorney, E.D.N.Y
BUSINESS & EMPLOYMENT LITIGATION CASE STUDIES
PBM Case
Studies

Recent Business & Employment Litigation Wins

Learn directly from healthcare providers who faced business disputes or employment issues—with our assistance, they fought back and won.
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BUSINESS LITIGATION WIN 1

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BUSINESS LITIGATION WIN 2

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Awards & Recognition
Our process

PBM Audit Defense Process

01

Initial Strategy Session

We use a free consultation to understand the specifics of your business dispute or employment issue, gather background information, and identify legal risk factors.
02

Detailed Case Analysis

Our team constructs a compelling factual narrative to support your position and identify any overreach or misconceptions by the opposing party.
03

Legal Analysis

Our detailed legal strategy leverages federal and state law to protect your rights and hold the opposing party accountable for their legal obligations and contractual commitments.
04

Negotiation & Litigation

We use our knowledge of the legal system and industry-specific processes to obtain favorable settlements, win in court, or achieve your desired outcome through alternative dispute resolution methods.
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FAQ

Frequently Asked Questions

What documents and data should I gather?

Initially, we'll need contracts, correspondence, employment agreements, and any other relevant documentation related to your business dispute or employment issue. As we develop your legal strategy, additional documentation may be requested. We will provide specifics on supporting materials.

What recourse exists if the other party violates contracts or employment laws?

What recourse exists if the other party violates contracts or employment laws?

Do business and employment disputes target specific types of healthcare providers?

Any healthcare provider can face business disputes or employment issues, but some specialties or practice types may be more prone to certain types of legal challenges. Having experienced legal advocates levels the playing field.

Can you help if my practice's viability or operations are jeopardized?

Yes. We ensure that any legal actions taken against your practice comply with applicable federal and state laws. We work to protect your practice's viability and operations throughout the legal process.

Will pursuing legal action impact my business relationships?

We understand the importance of maintaining business relationships whenever possible. We incorporate proper legal protections and consider the potential impact on your relationships when developing your legal strategy.

What are the costs of legal representation?

We offer flexible fee arrangements based on the scope of representation required and the stage of your business dispute or employment issue. The earlier we are involved, the better, as we can shape the legal strategy, making representation more effective and less costly.

Can your guidance help prevent future business or employment disputes?

Absolutely. We provide tailored recommendations to help healthcare providers reinforce their contracts, employment policies, and business practices. Proper documentation and proactive measures are critical to minimizing future legal risks.

Can business or employment litigation impact my professional reputation?

Potentially. Depending on the nature of the dispute and the outcome of the case, your professional reputation could be affected. Our specialists work to minimize any negative impact on your reputation and protect your standing in the healthcare community.

Health Law Alliance

Book a Free Consultation

We protect your rights and interests in business disputes and employment issues. Do not wait until your practice is jeopardized. Schedule a free consultation now.

PBM AUDIT STRATEGY

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.