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Faced With a Whistleblower? Weak Allegations Crumble Under Pressure

Whistleblower & Civil Investigative Demand Defense Attorneys

Whistleblower lawsuits and Civil Investigative Demands (CIDs) can result in devastating consequences, including substantial penalties, reputational harm, and even criminal prosecution. Your initial response to a whistleblower complaint or CID is critical. Do not wait until your rights are lost.

Healthcare providers need to hold whistleblowers and government agencies accountable for their legal obligations and the merits of their claims. Our attorneys have extensive experience defending against whistleblower actions and responding to CIDs. No one understands the laws applicable to these matters better than us. Our nationally recognized team of whistleblower and CID defense attorneys has decades of combined experience in the healthcare industry and legal field. Put our inside knowledge and expertise on your side today. If you are facing a whistleblower lawsuit or CID, act now.

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200+

WHISTLEBLOWER LAWSUITS DEFENDED
Past Experience
WHISTLEBLOWER & CID EXPERTISE

Pharmacy Audit Defense Lawyers

Our whistleblower and CID defense team has helped clients avoid millions of dollars in penalties, protect their reputations, and defend against aggressive government tactics.

We provide expert legal advice tailored to your specific circumstances using our knowledge of whistleblower and CID strategies 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 whistleblower and CID defense 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
WHISTLEBLOWER & CID CASE STUDIES
PBM Case
Studies

Recent Whistleblower & CID Wins

Learn directly from healthcare providers who were targeted by whistleblower lawsuits and CIDs—with our assistance, they fought back and won.
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WHISTLEBLOWER WIN 1

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WHISTLEBLOWER 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 the whistleblower complaint or CID, gather background information, and identify potential risk factors.
02

Detailed Allegations Analysis

Our team constructs a compelling factual narrative to counter the whistleblower's allegations or CID's scope and identify any overreach or misconceptions.
03

Legal Analysis

Our detailed response rebuts any allegations and uses federal and state law to protect your rights and hold the whistleblower or government accountable for their legal obligations.
04

Resolution & Defense

We use our knowledge of the legal system and government processes to obtain favorable resolutions, negotiate settlements, and mount a strong defense in court if necessary.
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FAQ

Frequently Asked Questions

What documents and data should I gather?

Initially, we'll need copies of the whistleblower complaint or CID, any correspondence with the whistleblower or government, and relevant financial or patient records. As we formulate legal arguments, additional documentation may be requested. We will provide specifics on supporting materials.

What recourse exists if proper procedures aren't followed?

Lack of proper notice or procedural violations can provide leverage in negotiations with the whistleblower or government. We hold them accountable and use any missteps to protect your interests.

Do whistleblowers or CIDs mainly target specific types of providers?

Whistleblowers and government agencies can target any healthcare provider, but some specialties or practice types may face heightened scrutiny. Having experienced legal advocates levels the playing field.

Can you help if my license or ability to practice is jeopardized?

Yes. We ensure that any actions taken by the whistleblower or government comply with applicable federal and state laws. They are prohibited from acting in bad faith or arbitrarily under the law.

Will responding to the whistleblower or CID impact my practice?

Retaliation for exercising your legal rights is prohibited. We incorporate proper legal protections into our responses and interactions with the whistleblower or government. Maintaining your ability to practice 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 the whistleblower lawsuit or CID. The earlier we are involved, the better, as we can shape the case's scope, making legal representation more effective and less costly.

Can your guidance help prevent future whistleblower lawsuits or CIDs?

Absolutely. We provide tailored compliance recommendations so healthcare providers can reinforce areas prone to whistleblower or government scrutiny. Proper documentation and compliance are critical to avoiding future legal issues.

Can whistleblower lawsuits or CIDs impact my participation in government programs?

Potentially. Depending on the scope of the allegations and the outcome of the case, your participation in Medicare, Medicaid, or other government programs could be affected. Our specialists ensure that any consequences are handled properly and your rights are protected.

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We hold whistleblowers and government agencies accountable and protect your rights during whistleblower lawsuits and CID proceedings. Do not wait until your rights are lost.

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.