You Have an Ally in Our healthcare fraud defense team

Board Investigation & Fair Hearing Defense Attorneys for Healthcare Practitioners

When Your Professional License is at Risk, Get Expert Help

Board investigations and disciplinary proceedings can have devastating consequences for healthcare practitioners, including license suspension, practice restrictions, and reputational damage. Your response to a board investigation or notice of a fair hearing is critical. Do not wait until your rights are lost. Healthcare practitioners need to hold licensing boards accountable for their legal obligations and due process requirements. Our attorneys have extensive experience defending physicians and mid-level practitioners in board investigations and fair hearings. No one understands the laws and regulations applicable to healthcare licensing better than us. Our nationally recognized team of professional license defense attorneys has decades of combined experience in the healthcare industry and legal field. Put our inside knowledge and expertise on your side today. If you are facing a board investigation or fair hearing, act now.

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75+

BOARD INVESTIGATIONS & FAIR HEARINGS DEFENDED
Past Experience
BOARD INVESTIGATION & FAIR HEARING EXPERTISE

Healthcare Fraud Defense Lawyers

Our board investigation and fair hearing defense team has helped healthcare practitioners protect their licenses, maintain their practice rights, and defend against unwarranted disciplinary actions.

We provide expert legal advice tailored to your specific circumstances using our knowledge of the board's investigative process and potential pitfalls. As lawyers, we leverage federal and state law to protect your rights.

When your professional license and livelihood are threatened, our team of experienced attorneys is your fiercest ally.

1200+

Clients served

2500+

matters handled

24/7

availability

100%

flexible rates
Our PBM audit defense team has helped clients avoid millions of dollars in recoupments, remain in-network, win reinstatement, and defend themselves against abusive PBM tactics.

When your license or livelihood is threatened, our team of pharmacy PBM audit attorneys is your fiercest ally.

1500+

Clients served

5000+

matters handled

24/7

availability

100%

flexible rates
"Anthony is the definition of a 'plug and play' athlete. Put him the game and he will change it."
- Former Acting U.S. Attorney, E.D.N.Y
BOARD INVESTIGATION & FAIR HEARING CASE STUDIES
PBM Case
Studies

Recent Board Investigation & Fair Hearing Wins

Learn directly from healthcare practitioners who faced board investigations and disciplinary proceedings—with our assistance, they fought back and won.
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BOARD INVESTIGATION WIN 1

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Awards & Recognition
Our process

Healthcare Fraud Defense Strategy

01

Initial Strategy Session

We use a free consultation to understand the specifics of your board investigation or fair hearing, gather background documents, and identify key factors for your defense.
02

Detailed Investigation Analysis

Our team constructs a compelling factual narrative to support your position and identify any board overreach or misconceptions.
03

Legal Analysis

Our detailed defense strategy leverages federal and state law to protect your rights and hold the licensing board accountable for its legal obligations and due process requirements.
04

Negotiation & Representation

We use our knowledge of the board's internal processes to negotiate favorable resolutions, present a strong defense at fair hearings, and protect your professional license.
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FAQ

Frequently Asked Questions

What documents and data should I gather?

Initially, we'll need any correspondence from the licensing board about the investigation or fair hearing, your professional license, and relevant patient records or other evidence. As we develop your defense strategy, additional documentation may be requested. We will provide specifics on supporting materials.

What recourse exists if the board fails to follow proper procedures?

Failure to follow proper investigation or fair hearing procedures can provide leverage in negotiations and legal proceedings. We hold licensing boards accountable for any procedural violations or due process infringements.

Do board investigations target specific types of healthcare practitioners?

Any healthcare practitioner can face a board investigation, but some specialties or practice types may face heightened scrutiny. Having experienced legal advocates levels the playing field.

Can you help if my license is suspended or restricted during the investigation?

Yes. We work to ensure that any interim actions taken by the board comply with applicable laws and due process requirements. We advocate for your right to practice while the investigation is ongoing.

Will defending against a board investigation or fair hearing impact my practice?

We incorporate proper legal protections into our defense process to minimize any disruption to your practice. Maintaining your ability to provide patient care is always a priority.

What are the costs of legal representation?

We offer flexible fee arrangements based on the scope of representation required and the stage of your board investigation or fair hearing. The earlier we are involved, the better, as we can shape your defense strategy, making representation more effective and less costly.

Can your guidance help prevent future board investigations?

Absolutely. We provide tailored recommendations to help healthcare practitioners maintain compliance and minimize the risk of board investigations. Proper documentation and adherence to professional standards are critical.

Can board investigations impact my participation in insurance networks or hospital privileges?

Potentially. Board investigations and disciplinary actions can impact your professional reputation and relationships. Our specialists work to minimize any negative consequences and protect your ability to practice and serve patients.

Health Law Alliance

Book a Free Consultation

We hold licensing boards accountable to their legal and procedural obligations. Do not wait until your professional license is at risk. Schedule a free consultation now.

PBM AUDIT STRATEGY

PBM Audit Information

The Role of Pharmacy Benefit Managers in Pharmacy Audits

To design an effective PBM audit response strategy, providers must understand the chain of events both prior to the initiation of a PBM audit and afterwards. For example, Special Investigative Units (SIUs) are often the genesis of a pharmacy audit, and the presence or absence of "audit risk factors" is informative on potentially broader exposure beyond the claims under audit. Any decision to resolve an audit should be informed and result in a full and final settlement of all liability, but PBM audit settlements need to be structured carefully to achieve this goal.

PBMs that Conduct the Most Pharmacy Audits


CVS Caremark, OptumRx, and Express Scripts, control at least 80% of the market, making them the three biggest PBMs. Humana also ranks among the largest. In addition, these PBMs regulate access to networks for smaller competitors, such as ESI's partnership with Prime. Plan sponsors, such as United Health, Cigna and Aetna, are vertically integrated with these PBMs, increasing audit risk for pharmacies because network sanctions are more likely to affect a significant aspect of a pharmacy's business across both government and commercial claims.

Common Pharmacy Audit Areas


PBMs and payors use artificial intelligence and data mining across medical and pharmacy claims to identify areas of potential inquiry. Among other areas, these inquiries typically involve high-reimbursing medicines, brand/generic substitution, inventory discrepancies, co-payment collection, prior authorization, and telehealth relations. Separately, DEA conducts audits and inspections for compliance to controlled substance regulations.  

Types of Pharmacy Audits


Common types of PBM audits include desk audits; on-site audits; invoice audits; and prescription audits. Irrespective of the type of PBM audit, all interactions with PBMs should be taken extremely seriously and can lead to severe consequences if not handled appropriately. For example, there has been a sharp increase in the federal prosecution of pharmacists for audit-related conduct, including answering PBM questions incorrectly. Accordingly, pharmacies should consider using outside audit counsel to avoid these pitfalls.

Preparing for Pharmacy Audits


Pharmacies can take various steps to prepare to meet PBM audits, including routine self-audits. In fact, the government publishes comprehensive guidance and a checklist to assist pharmacies in their audit planning, including self-audits around prescribing practices, controlled substance management, invoice management, and billing practices. If you need assistance designing or implementing an audit protection plan, please do not hesitate to contact us.

Defending Pharmacy Audits


Defending against a PBM audit requires comprehensive knowledge of the rights, responsibilities, and intricacies of pharmacies and their laws and regulations.  If your pharmacy has been identified for a PBM audit, there are a number of potential defenses available to you. The first defense against a PBM audit is to be proactive, and audit planning can lessen the chance of unfavorable findings. That said, it is often necessary to involve an attorney to hold PBMs to their obligations under law and provider agreements. For this reason, national audit services and pharmacy audit consultants are often ineffective.

Pharmacy Audit Appeals


Audit discrepancies and findings can be appealed based on the specific procedures outlined in the provider manuals. It is important to follow these requirements exactly, within the timeframes established, or your appeal rights could be lost and further review denied. In an appeal, it is critically important to make a complete record of why the audit findings or sanctions should be reversed, including through documentation, legal arguments, and corrective actions, if any. Depending on the outcome of the appeal, you may have further legal recourse against the PBM.

Potential Consequences of Pharmacy Audits

PBM audits can have severe repercussions depending on the results of the pharmacy audit, including recoupments, network sanctions, and criminal, civil and administrative investigations involving jail time, significant fines, and license revocation or exclusion. We publish a 10-part PBM Audit Guide that discusses the overlap between PBM audits and government investigations and how to successfully manage audit risk. This resource is complimentary to subscribers HERE.