PBM

Medicare Advantage Cuts to Increase PBM Pressures

Insurers have bet big on Medicare Advantage, but the government is slowly cutting back. Faced with rising medical loss ratios and CMS reimbursement cuts, payors and their PBMs are planning to make up those losses by increasing pharmacy claims audits and unilateral recoupments.

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Safeguarding Independents: HLA Reverses PBM Termination on Appeal

PBMs are huge companies that often use their market power in an abusive and predatory manner. This case study and successful network appeal provides an example of why experienced PBM audit defense attorneys are necessary to hold PBMs legally accountable and protect your rights.

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National Audit Services are No Replacement for Attorney Advice

National audit assistance services cannot provide the legal expertise, subject matter knowledge, or audit leverage that healthcare defense attorneys bring to the table. These services are ineffective in holding PBMs accountable to their legal obligations.

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MFCU Agrees Not to Charge HLA Client Following PBM Audit Referral

PBM audits must be handled correctly or severe consequences may result. In this case, HLA was able to persuade prosecutors not to file criminal charges against the pharmacy's owner, but a subsequent civil resolution still involved harsh penalties. It could have been far worse.

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Federal Prosecutors Decline Criminal Prosecution of HLA Client

Following a PBM audit that uncovered a $6.5 million billing discrepancy, federal prosecutors opened an investigation. After HLA was retained, the U.S. Attorney's Office for the Eastern District of Pennsylvania agreed to a $2.5 million civil settlement in which the Owner denied all wrongdoing.

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State Board Declines Case Against HLA Client

PBM audits may result in collateral consequences, including licensing and disciplinary proceedings. In this case, HLA's experienced defense attorneys successfully convinced the State Board to decline further investigation, effectively resolving the matter at an early stage.

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HLA Wins Network Reinstatement for Illinois Pharmacy

PBMs are increasingly terminating pharmacies for minor infractions of the provider manuals or network enrollment forms. These terminations are contrary to the PBM's obligations under law and the parties' agreements, and may have collateral consequences if the underlying allegations involve wrongdoing. In this case, we profile the steps that led to a successful network reinstatement for an Illinois pharmacy.

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PBM Audit Response Summary

PBM audits can be resolved successfully, but more frequent and aggressive audits will require careful planning. Providers should avoid reactive behavior. Strategic planning for audit resolution should be made from audit inception to proactively manage audit risk effectively.

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NYRx Transition May Increase Medicaid Program Risk

The transition of Medicaid pharmacy benefit to NYRx in New York brings increased dispensing fees but also heightened audit and enforcement risks, with potential scrutiny from OMIG and HHS-OIG, warns Health Law Alliance led by Anthony Mahajan.

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How PBM Audits Can Provoke Government Scrutiny

Health Law Alliance's Anthony Mahajan discusses the potential outcomes and strategies related to Pharmacy Benefit Manager (PBM) audits, emphasizing the importance of understanding the intersection between government enforcement actions and PBM audits. With unmatched experience in PBM audit defense, Mahajan highlights the firm's achievements in resolving cases involving inventory discrepancies and government investigations, offering comprehensive solutions to protect clients against potential liabilities.

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Inventory Shortfall Case Studies

Health Law Alliance, under Anthony Mahajan's leadership, celebrates favorable outcomes in federal and state cases involving inventory shortfalls, showcasing their expertise in PBM audit defense. Successful dismissals of criminal charges and reduced civil settlements highlight Health Law Alliance's strategic approach in resolving cases stemming from PBM audits.

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Key PBM Audit Considerations

Health Law Alliance provides an overview of the PBM audit process and relevant background for providers who suddenly find themselves facing arbitrary recoupments and potentially devastating network consequences. PBM audits are not random or happenstance, and providers must understand the role of Special Investigative Units (SIUs) and the potential for broader liability beyond the audit itself to successfully manage these risks.

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Defending Inventory Shortfalls

Health Law Alliance addresses the complexities of defending against inventory shortfalls in the context of PBM audits, emphasizing the common sources of discrepancies and potential legal implications. The article underscores the importance of a well-organized defense strategy to limit liability and navigate potential consequences for providers facing network suspension, administrative proceedings, civil lawsuits, or even criminal charges arising from inventory management errors.

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Potential Windows of Opportunity

Health Law Alliance, specializing in PBM audit defense, highlights the potential benefits of discrepant PBM audits as early warnings for broader government investigations. The article underscores the importance of strategic planning, including OIG self-disclosures, to reduce liability for providers facing PBM audits and government inquiries.

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OIG’s Self-Disclosure Protocol

Healthcare providers facing PBM audits can leverage the OIG's Self-Disclosure Protocol (SDP) to reduce liability by self-reporting potential violations of laws, benefiting from reduced penalties and additional incentives. The complex SDP process, involving full disclosure and liability limitations, underscores the importance of seeking guidance from experienced healthcare defense counsel.

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When to Seek Help

Providers facing PBM audits must decide whether to rely on internal staff or seek audit counsel from experienced attorneys, particularly when concerns about audit scope or risk factors arise. HLA's attorneys, with prosecutorial background, offer crucial insights and protection against potential legal consequences during pharmacy audits.

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Audit-Related Prosecutions Rise Sharply

Federal prosecutors are now pursuing felony charges under Section 1035 for false statements in pharmacy audits, extending the risk of criminal prosecution for healthcare providers. Recent cases highlight the importance of legal counsel, such as HLA's experienced attorneys, to safeguard against potential legal consequences.

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