You Have an Ally in Our healthcare fraud defense team

Nationally Recognized Healthcare Fraud Defense Attorneys

Accused of Healthcare Fraud? Get Expert Help Now.

Healthcare fraud investigations often have devastating consequences if not handled properly, including substantial fines, exclusion from federal healthcare programs, and even lengthy prison sentences. Act Immediately to Protect Your Rights and Reputation from Unfounded Charges.

Our healthcare fraud defense lawyers have more than 40 years of proven results and a demonstrated track record of success. We understand the government's playbook in healthcare fraud cases because our lawyers have decades of experiences as former, highly decorated federal and state prosecutors.

We specialize in neutralizing healthcare fraud investigations before they become threats. Do Not Wait Until the Deck is Stacked to Take Action. At the first sign of a government investigation, put our aggressive healthcare fraud defense lawyers in your corner. We will fight to prove your innocence and clear your name. Call Now.

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500+

HEALTHCARE FRAUD CASES handled
Past Experience
HEALTHCARE FRAUD specialists

Healthcare Fraud Defense Lawyers

Our healthcare fraud defense team has helped clients avoid federal and state criminal charges, maintain their professional licenses, achieve civil and administrative settlements for large discounts on the dollar value of the claims at issue, and win outright dismissals of unfounded criminal charges pre-trial.

When your reputation, livelihood, or freedom is threatened, our team of experienced healthcare fraud defense attorneys is your strongest advocate. We have litigated hundreds of healthcare fraud and criminal cases in courtrooms across the country, and successfully settled many more before charges were brought.

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
HEALTHCARE FRAUD CASE STUDIES
PBM Case
Studies

Recent Healthcare Fraud Defense Victories

Learn about providers who were targeted for criminal healthcare fraud charges by government prosecutors; with our assistance, they fought back and won.
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Healthcare Defense Win 1

Case Study

  • Philadelphia
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Healthcare Defense Win 2

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Healthcare Defense Win 3

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Awards & Recognition
Our process

Healthcare Fraud Defense Strategy

01

Initial Case Assessment

We use a free consultation to understand the specifics of your case, gather relevant documents, and identify potential defenses and strategies.
02

Comprehensive Investigation

Our team conducts a thorough investigation to construct a compelling factual narrative that counters the government's allegations and exposes any misconduct or overreach.
03

Legal Analysis and Defense

Our detailed defense strategy leverages federal and state law to hold the government accountable for its obligations and protect your rights throughout the process.
04

Negotiation and Resolution

We use our knowledge of the government's internal processes to obtain favorable settlements, win dismissals, or mount a vigorous defense at trial when necessary.
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FAQ

Frequently Asked Questions

What documents and information should I prepare for my initial consultation?

Initially, we'll need any documents related to the investigation, such as subpoenas, search warrants, or correspondence with government agencies. As we develop your defense strategy, we may request additional documentation. We will provide specific guidance on the most relevant supporting materials for your case.

What should I do if I'm contacted by investigators without warning?

If investigators arrive unannounced or contact you without prior notice, politely decline to answer questions and inform them that you will have your attorney contact them. Immediately reach out to our healthcare fraud defense team so we can assess the situation and advise you on the best course of action.

Do healthcare fraud investigations target specific types of providers?

While certain sectors, such as home health, hospice, and durable medical equipment, have been the focus of increased scrutiny, all healthcare providers must contend with the risk of fraud allegations. Having experienced legal advocates levels the playing field and ensures your rights are protected.

Can you help if my DEA registration or medical license is jeopardized?

Yes. We work tirelessly to ensure that any potential sanctions comply with applicable federal and state laws and that your rights as a healthcare provider are vigorously defended. Government agencies are prohibited from acting in bad faith or arbitrarily, and we hold them accountable.

Will cooperating with the investigation impact my professional licenses or contracts?

While cooperation is often advisable, it's crucial to have legal representation to protect your rights and interests. We incorporate proper legal safeguards into any interactions with investigators. Maintaining your professional standing and contracts is always a priority.

What are the costs of legal representation in a healthcare fraud case?

We offer flexible fee arrangements based on the scope of representation required and the stage of the investigation. The earlier we are involved, the better, as we can help shape the direction of the investigation and implement a more effective defense strategy, ultimately making legal representation more cost-efficient.

Can your guidance help prevent future fraud allegations?

Absolutely. We provide tailored compliance recommendations to help healthcare providers reinforce areas prone to government scrutiny. Proper documentation and adherence to billing regulations are critical to minimizing the risk of fraud allegations.

Can a healthcare fraud investigation impact my participation in federal healthcare programs?

Potentially. Depending on the scope of the investigation and the allegations involved, your participation in Medicare, Medicaid, or other federal healthcare programs may be at risk. Our specialists work to minimize any potential consequences and ensure that your rights are protected throughout the process.

Health Law Alliance

Book a Free Consultation

We hold government investigators accountable and protect your rights throughout the healthcare fraud defense process. Do not wait until your reputation or livelihood is jeopardized. Schedule a free consultation now to discuss your case and explore your options.

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.