You Have an Ally in Our Pharmacy Law Firm

When Network Terminations Threaten Your Business, Get Expert Help

Network Termination & Appeal Attorneys for Pharmacies

PBM network terminations can result in devastating consequences, including loss of patients, revenue, and even the viability of your pharmacy. Your response to a network termination notice is critical. Do not wait until your rights are lost.

Pharmacies need to hold PBMs accountable for their legal obligations and provider agreements. Our founding partner was a top executive for United Health, overseeing the OptumRx PBM. No one understands the law applicable to PBM network terminations 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 a network termination, act now.

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150+

TERMINATION CASES HANDLED
Past Experience
NETWORK TERMINATION & APPEAL EXPERTISE

Pharmacy Audit Defense Lawyers

Our network termination and appeal team has helped clients remain in-network, win reinstatement, and defend against unfair PBM practices.

We provide expert legal advice tailored to your specific circumstances using our knowledge of PBM network agreements and appeal processes. As lawyers, we leverage federal and state law to protect your rights. When your pharmacy's network status and livelihood are threatened, 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
NETWORK TERMINATION CASE STUDIES
PBM Case
Studies

Recent Network Termination & Appeal Wins

Learn directly from pharmacy owners who faced PBM network terminations—with our assistance, they fought back and won.
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NETWORK TERMINATION WIN 1

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NETWORK TERMINATION WIN 2

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NETWORK TERMINATION WIN 3

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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 network termination, gather background documents, and identify key factors for your appeal.
02

Detailed Termination Analysis

Our team constructs a compelling factual narrative to counter the PBM's termination decision and identify any overreach or misconceptions.
03

Legal Analysis

Our detailed appeal leverages federal and state law to hold the PBM accountable for its contractual obligations and any violations of law.
04

Negotiation & Resolution

We use our knowledge of the PBM's internal processes to negotiate favorable resolutions, win appeals, and secure your network status.
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FAQ

Frequently Asked Questions

What documents and data should I gather?

Initially, we'll need the network termination notice, your provider agreement, and any correspondence with the PBM. As we develop your appeal strategy, additional documentation may be requested. We will provide specifics on supporting materials.

What recourse exists if proper notice isn't provided?

Lack of proper notice or failure to follow contractual termination procedures can provide leverage in your appeal. We hold PBMs accountable for any procedural violations.

Do network terminations target specific pharmacy types?

PBMs often unfairly target independent, specialty, and compounding pharmacies for network termination. But all pharmacy types must contend with the risk of termination. Having legal advocates levels the playing field.

Can you help if my pharmacy's viability is jeopardized by a termination?

Yes. We work to ensure that any termination complies with applicable federal and state laws and your provider agreement. PBMs are prohibited from acting in bad faith or arbitrarily terminating pharmacies.

Will filing an appeal impact my other network contracts?

Retaliation for exercising appeal rights is prohibited. We incorporate proper legal protections into your appeal and negotiations. Maintaining your network status and contracts 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 network termination. The earlier we are involved, the better, as we can shape your appeal strategy, making legal representation more effective and less costly.

Can your guidance help prevent future network terminations?

Absolutely. We provide tailored recommendations to help pharmacies maintain compliance and strong network relationships. Proper documentation and adherence to PBM requirements are critical to minimizing termination risks.

Can network terminations impact my pharmacy's reimbursements?

Potentially. A network termination can impact your reimbursements and patient access. Our specialists work to minimize any negative impact on your pharmacy's financial standing and ability to serve your patients.

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Book a Free Consultation

We hold PBMs accountable to their contractual and legal obligations. Do not wait until your pharmacy's network status is lost. 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.