.png){kind=spacer}
Our client, a Philadelphia pharmacy, was referred to the Prosecution Division of the Pennsylvania Department of State's Office of Chief Counsel following a PBM audit that noted violations. After the pharmacy retained HLA, the State declined to prosecute the case.
PBM Audits May Result in Referrals
We have written extensively about how PBM audits can lead to collateral consequences, including referral to state Medicaid agencies and Boards of Pharmacy. Accordingly, PBM audits need to be handled with extreme care, particularly when dealing with the larger PBMs or payors, most of whom cultivate close relationships with state and federal agencies.
In fact, PBM and payors often hire claims auditors and investigators from agencies such as the Department of Insurance or Medicaid Fraud Control Unit. In Pennsylvania, Keystone maintains particularly close relationships with federal and state agencies.
If you would like to read more about PBM audits and important considerations, please sign-up HERE for our complimentary, 10-part PBM Audit Guide.
HLA's Defense Strategy
Because our attorneys have worked as federal and state regulators, we understand the considerations at play. Overall, we use that insight to present our client's narrative in a convincing and compelling manner to assuage any regulatory concerns. In addition, it is always important to provide convincing evidence that the conduct at issue is isolated, and will not recur.
State Officials Declined to Prosecute
Based on our factual and legal arguments, the State declined to take further action and closed its file. We are grateful to the State for their consideration, as we strive to achieve successful outcomes as early in the process as possible. This approach is not only efficient for all involved, but spares the stress and anxiety involved in a drawn-out dispute.
With HLA's assistance, our client achieved a speedy and efficient final resolution, and can now refocus his energy where it should be, on running his business.
MORE ARTICLES BY CATEGORY
Telehealth Audit Season: OIG Found 7 Percent Error Rate in Pandemic-Era E/M Billing
A 2024 OIG study found that 7% of E/M services billed during the pandemic were noncompliant with Medicare billing requirements. We break down OIG’s findings and explain what they mean in an era where RPM audits are on the rise.
Read More >>Health Law Alliance Earns Reinstatement for DME Supplier Whose Medicare Billing Privileges Were Unjustly Revoked
Due to Health Law Alliance’s advocacy, a prominent DME vendor in Texas had their billing privileges reinstated this week, without having to jump through the arduous, costly hoops of a fair hearing in front of an Administrative Law Judge or a Departmental Appeals Board review.
Read More >>Balancing Patient Access and Privacy in Audio-Only Telehealth
Address the specific compliance and privacy challenges associated with audio-only telehealth services. This article will provide telehealth providers with actionable strategies to ensure compliance with privacy regulations, such as HIPAA, while effectively using audio-only visits to increase access to care.
Read More >>10 Telehealth Fraud Red Flags (and How to Avoid Them)
Provide telehealth providers with a concise guide to recognizing and mitigating potential fraud risks. Each “red flag” will highlight a common scenario that could indicate fraud vulnerability, followed by practical steps to address it. With clear, actionable insights, the article will be an essential resource for telehealth providers aiming to safeguard their practice.
Read More >>
