A PBM audit can quickly become an existential threat to an independent pharmacy. In a recent matter, Health Law Alliance successfully defended a community pharmacy facing potential OptumRx network termination following audit allegations involving claim submissions and billing practices.
The pharmacy’s ability to remain in-network and continue serving its patients depended on a prompt, strategic response to the PBM’s audit findings.
A PBM Audit Does Not Have to End in Termination
PBMs increasingly rely on alleged billing irregularities, documentation gaps, return-to-stock concerns, and operational issues to support severe network action. But an audit finding is not the final word. Many alleged discrepancies stem from workflow problems, incomplete records, or misunderstandings that can be addressed through a properly developed defense.
HLA conducted a detailed review of the audit allegations, claims information, and the pharmacy’s operational records. By developing a focused response and guiding the pharmacy through the corrective action and compliance process, HLA’s PBM audit defense attorneys prevented the pharmacy’s exclusion from participating in the PBM’s network.
The Result: Network Participation Preserved
Instead of losing access to a critical PBM network, the pharmacy was able to continue operating, serving patients, and preserving essential reimbursement relationships. The result underscores an important point for every pharmacy facing an audit: early, well-documented advocacy can make the difference between a manageable compliance process and a devastating network termination.
How HLA Can Help
Health Law Alliance represents pharmacies nationwide in PBM audits, recoupment disputes, and PBM network termination appeals. Our PBM audit defense attorneys help pharmacies evaluate PBM audit findings, prepare strategic responses and appeals, navigate the corrective action processes, and protect network participation.
If your pharmacy has received a PBM audit notice, adverse PBM audit findings, or a PBM network termination letter, contact HLA today for a free consultation.