In another decisive win for independent pharmacies, Health Law Alliance successfully overturned more than $30,000 in alleged inventory discrepancy findings asserted by Express Scripts’ Special Investigations Unit (SIU) against a Texas pharmacy. This outcome underscores the critical importance of experienced legal representation when navigating PBM audits, particularly those involving complex inventory and billing issues.
Express Scripts (ESI) initiated a Fraud, Waste, and Abuse (FWA) investigation under Section 5.8 of its Provider Manual, alleging significant inventory shortages and NDC-level discrepancies within the pharmacy’s reconciliation records. After the pharmacy engaged Health Law Alliance, the firm’s audit defense team conducted a meticulous review of the findings, supplier records, and dispensing data.
Following extensive correspondence and multiple evidentiary submissions on behalf of the pharmacy, ESI issued an updated Final Discrepancy Evaluation Report fully resolving its prior allegations related to inventory discrepancies. The final determination acknowledged that all previously identified inventory shortages had been fully reconciled and remedied. This result effectively reversed more than $30,000 in alleged inventory discrepancies, sparing the pharmacy from unwarranted recoupment.
Inventory discrepancy findings remain among the most common, and most perilous, issues raised during PBM audits. Even minor reconciliation variances can prompt allegations of billing irregularities or FWA. In this case, ESI’s initial conclusions were based on incomplete data that failed to capture delayed wholesaler reporting. Without timely and strategic intervention, these errors could have resulted in tens of thousands of dollars in financial exposure for the pharmacy.
The successful reversal of more than $30,000 in alleged findings demonstrates the importance of responding to PBM audits with precision and strategy. Thorough supplier documentation, coupled with legal advocacy attuned to both contractual nuances and regulatory frameworks, can transform what appears to be a losing audit into a victory.
This case illustrates the power of evidence-based legal defense, a cornerstone of Health Law Alliance’s audit strategy. By combining deep industry knowledge with exhaustive documentary analysis, the firm overturned inflated findings and prevented a substantial and unjustified recoupment.
How Health Law Alliance Can Help
Health Law Alliance represents pharmacies nationwide in PBM audits, PBM network terminations, and regulatory enforcement actions. When facing an audit, timing and strategy are everything. Whether your pharmacy is responding to a PBM audit, contesting a termination, or proactively strengthening its compliance protocols, Health Law Alliance delivers the expertise and results that make a difference. Contact us today for a free legal consultation.
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