
Frequently Asked Questions
Can I join HLA's lawsuit against Optum Rx for PBM audit termination?
Unfortunately, PBM provider manuals contain provisions that prohibit "class actions," meaning the joining of multiple plaintiffs against a defendant in one complaint.
Am I able to file a lawsuit against Optum Rx for PBM audit violations?
Yes, you are entitled to file a lawsuit in federal or state court to hold the PBM accountable for PBM audit violations. Ultimately, however, lawsuits should be a remedy of last resort if PBM audit negotiations fail.
What are the costs associated with filing a PBM audit lawsuit?
Legal fees and expenses vary depending on the nature of the lawsuit and claims involved. Some PBM audit lawsuits may be resolved quickly, whereas others may take longer or be referred to arbitration. Finally, certain claims may be eligible for "contingent fee" arrangements, particularly if you are a specialty pharmacy with high DIR claw-backs.
Just days after we sued Optum in federal court in the Northern District of Texas, Optum immediately released approximately $250,000 in reimbursement that it had unlawfully withheld from our client for more than six months on the basis of non-existent PBM audit discrepancies. The fact that we had to sue Optum to obtain this relief serves as another example of the extent to which PBMs abuse their market position at the expense of network pharmacies.
Texas Lawsuit to Stop PBM Audit Violations is Continuing
Although Optum has now returned our client's money, we do not intend to stop there. We have filed an Amended Complaint that alleges that United Health is applying different PBM audit metrics and standards to pharmacies that service beneficiaries of United Healthcare's Part C Medicare Advantage capitated plans than other network pharmacies.
If you have been targeted for a PBM audit focused on claims for Medicare Advantage AARP members, or other United Healthcare sponsored plans, our experienced healthcare attorneys are available to defend the PBM audit.
Texas PBM Reform Permits Mail-Order Deliveries
In our case, Optum's PBM audit alleged that certain of the pharmacy's claims were invalid because they had been delivered by mail to patients located hundreds of miles away.
In Texas, however, PBM reform laws expressly forbid payors and PBMs from barring mail-order delivery. Accordingly, if you are a Texas provider and have been targeted for a PBM audit based on mail order deliveries, we can help you hold PBMs like Optum accountable to their legal obligations.
PBMs are Prohibited from Withholding Reimbursement
Many laws prohibit PBMs from refusing to reimburse "clean claims" within certain time periods. In our case, Optum withheld reimbursement due the pharmacy in violation of such "prompt pay" laws for more than six months. Once we sued Optum, it was forced to comply with the law.
Nonetheless, there may be scenarios in which a PBM is permitted by the terms of its agreements to hold funds pending completion of an audit. The extent to which a PBM may withhold reimbursement due and owing on certain claims pending an audit of other claims is highly dependent on the facts and legal obligations at play.
Nationwide PBM Audit Specialists
Although our lawsuit against Optum was filed in Dallas, Texas, our firm assists pharmacies and providers nationwide to defend PBM and payor audits. If you have been selected for a PBM audit, are appealing the results of that audit, or are facing network termination as a result of discrepant audit findings, our PBM audit defense specialists are available to help. Contact us today for a free consultation.
MORE ARTICLES BY CATEGORY
How DME Suppliers Can Maintain Compliance with Medicare Enrollment Requirements
If you are a Durable Medical Equipment (DME) supplier and you are fearful of being scrutinized by CMS or the National Provider Enrollment contractors for violating the onerous Medicare enrollment standards, we hope this article will help. It lays out the essential steps to maintain compliance with Medicare's enrollment requirements. We break down the complex regulations surrounding Medicare enrollment standards, covering everything from initial enrollment and accreditation to revalidation and reporting changes, and tells providers to reach out to Health Law Alliance if they are seeking advice.
Read More >>OIG Issues Advisory Opinion 25-03, A Roadmap for Compliant Telehealth Staffing Models
On June 6, 2025, the US Department of Health and Human Services’ Office of the Inspector General issued Advisory Opinion 25-03, offering key compliance guidance for telehealth arrangements involving the leasing of health care providers and other administrative services to a physician-owned professional corporation (PC). Learn more about the opinion and what it tells us about the future of telehealth regulatory compliance.
Read More >>HLA Wins Full Reversal of PBM Audit Findings for Maryland Pharmacy
Health Law Alliance achieved full reversal of final audit findings for a Maryland pharmacy—just one of numerous victories our attorneys has achieved for our clients. Learn more about the stunning reversal and how Health Law Alliance’s tenacious advocacy can help your pharmacy in PBM disputes.
Read More >>HLA Attorney Anthony Mahajan Secures Major Victory Over Cardinal as Federal Court Dismisses Lawsuit Against Independent Pharmacies
Health Law Alliance secured a major win for independent pharmacies with the dismissal of Cardinal Health’s lawsuit, exposing it as a baseless attempt to intimidate smaller providers. This outcome reinforces the firm’s commitment to protecting healthcare businesses from corporate overreach.
Read More >>