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.