You Have an Ally in Our Pharmacy Law Firm

Inventory & Prior Authorization Attorneys for Pharmacies

When Inventory and Prior Authorization Issues Threaten Your Business, Get Expert Help

Inventory shortfalls and prior authorization denials can result in serious consequences for your pharmacy, including financial losses, regulatory scrutiny, and patient care disruptions. Your approach to these challenges is critical. Do not wait until your rights are lost.

Pharmacies need to hold PBMs and regulatory agencies accountable for their legal obligations and contractual agreements. Our founding partner was a top executive for United Health, overseeing the OptumRx PBM. No one understands the law applicable to inventory and prior authorization better than us. Our nationally recognized team of pharmacy attorneys has more than 40 years of pharmacy and legal experience. Put decades of inside knowledge and expertise on your pharmacy's side today. If you are facing inventory or prior authorization issues, act now.

Content - Elements Webflow Library - BRIX Templates

100+

INVENTORY & PRIOR AUTHORIZATION CASES HANDLED
Past Experience
INVENTORY & PRIOR AUTHORIZATION EXPERTISE

Pharmacy Audit Defense Lawyers

Our inventory and prior authorization legal team has helped clients minimize financial losses, maintain regulatory compliance, and ensure patient access to medications. We provide expert legal advice tailored to your specific circumstances using our knowledge of inventory management requirements and prior authorization processes. As lawyers, we leverage federal and state law to protect your rights. When your pharmacy's operations and patient care are threatened by inventory or prior authorization issues, our team of experienced 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
INVENTORY & PRIOR AUTHORIZATION CASE STUDIES
PBM Case
Studies

Recent Inventory & Prior Authorization Wins

Learn directly from pharmacy owners who faced inventory shortfalls and prior authorization denials—with our assistance, they fought back and won.
Free Consultation
INVENTORY WIN 1

Headline 1

  • a
  • b
  • c
Read More
INVENTORY WIN 2

Headline 2

  • a
  • b
  • c

Read More
INVENTORY WIN 3

Headline 3

  • a
  • b
  • c

Read More
Awards & Recognition
Our process

PBM Audit Defense Process

01

Initial Strategy Session

We use a free consultation to understand the specifics of your inventory or prior authorization issue, gather background documents, and identify key factors for your case.
02

Detailed Issue Analysis

Our team constructs a compelling factual narrative to support your position and identify any regulatory or PBM mistakes or misconceptions.
03

Legal Analysis

Our detailed legal strategy leverages federal and state law to protect your pharmacy's interests and hold regulators and PBMs accountable for their obligations.
04

Resolution & Compliance Support

We use our knowledge of regulatory requirements and PBM processes to resolve issues, maintain compliance, and ensure patient access to medications.
As seen on
FAQ

Frequently Asked Questions

What documents and data should I gather?

Initially, we'll need any correspondence with regulators or PBMs about inventory or prior authorization, relevant inventory records, and prior authorization submissions. As we develop your legal strategy, additional documentation may be requested. We will provide specifics on supporting materials.

What recourse exists if regulators or PBMs fail to follow proper procedures?

Failure to follow proper inventory or prior authorization procedures can provide leverage in negotiations and legal proceedings. We hold regulators and PBMs accountable for any procedural violations.

Do inventory and prior authorization issues affect specific pharmacy types?

All pharmacy types must navigate complex inventory requirements and prior authorization processes, but some may face heightened scrutiny. Having legal advocates levels the playing field.

Can you help if my pharmacy's license or ability to dispense certain medications is jeopardized?

Yes. We work to ensure that any regulatory actions or PBM decisions comply with applicable federal and state laws. We protect your pharmacy's license and ability to serve patients.

Will seeking legal support for inventory or prior authorization issues impact my pharmacy's operations?

We incorporate proper legal protections into our support process to minimize any disruption to your pharmacy's operations. Maintaining your ability to serve patients is always a priority.

What are the costs of legal representation?

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

Can your guidance help prevent future inventory and prior authorization issues?

Absolutely. We provide tailored recommendations to help pharmacies maintain compliance and minimize inventory and prior authorization risks. Proper documentation and adherence to regulatory requirements are critical.

Can inventory and prior authorization issues impact my pharmacy's performance metrics?

Potentially. Inventory shortfalls and prior authorization denials can impact your pharmacy's performance metrics and patient care. Our specialists work to minimize any negative impact and ensure your metrics are properly calculated.

Health Law Alliance

Book a Free Consultation

We help pharmacies navigate complex inventory and prior authorization requirements. Do not wait until your pharmacy's compliance is questioned. 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.