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When Payor Audits Put Your Practice at Risk, Get Expert Help

Payor Audit & Practitioner Defense Attorneys

Payor audits can lead to severe consequences, including substantial recoupments, network exclusion, and even referrals for criminal investigation. Your initial response to a payor audit is critical. Do not wait until your rights are compromised.

Healthcare providers need to hold payors accountable for their legal obligations and provider agreements. Our founding partner has extensive experience working with major insurance companies and understanding their audit strategies. No one understands the law applicable to payor audits better than our team.

Our nationally recognized payor audit defense attorneys have more than 40 years of combined healthcare and legal experience. Put decades of inside knowledge and expertise on your practice's side today. If you are facing a payor audit, act now to protect your revenue and reputation.

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100+

PAYOR AUDITS DEFENDED
Past Experience
PAYOR AUDIT EXPERTISE

Healthcare Fraud Defense Lawyers

Our payor audit defense team has helped clients avoid millions of dollars in recoupments, maintain network participation, win appeals, and defend themselves against aggressive payor tactics.

When your practice's financial stability and reputation are threatened, our team of experienced payor audit attorneys is your strongest advocate.

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
PAYOR AUDIT CASE STUDIES
PBM Case
Studies

Recent Payor Audit Victories

Discover how healthcare providers targeted by payor audits and faced with substantial recoupment demands fought back and won with our expert legal representation.
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PAYOR AUDIT WIN 1

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PAYOR AUDIT WIN 2

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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 audit, gather relevant documents, and identify potential defenses and strategies.
02

Comprehensive Audit Review

Our team conducts a thorough review of the audit findings to construct a compelling factual narrative that counters the payor's allegations and exposes any overreach or misinterpretations.
03

Legal Analysis and Response

Our detailed response leverages federal and state law to hold the payor accountable for its obligations and protect your rights throughout the audit process.
04

Negotiation and Appeals

We use our knowledge of the payor's internal processes to obtain favorable settlements, win appeals, and preserve your hard-earned revenue.
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FAQ

Frequently Asked Questions

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

Initially, we'll need any audit notification letters, audit reports, and relevant financial records, such as billing statements and remittance advices. 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 the payor conducts an audit without providing sufficient notice?

Lack of proper notice or failure to adhere to contractual audit requirements may violate state laws or your provider agreement. We leverage these issues to negotiate more favorable outcomes and protect your rights during the audit process.

Do payors target specific types of healthcare providers for audits?

While certain specialties or provider types may face increased scrutiny, all healthcare providers must contend with the risk of payor audits. Having experienced legal advocates levels the playing field and ensures your rights are protected.

Can you help if my network participation or credentialing is jeopardized?

Yes. We work tirelessly to ensure that any potential sanctions comply with applicable laws and your provider agreement. Payors are prohibited from acting in bad faith or arbitrarily, and we hold them accountable to protect your practice.

Will appealing audit findings or negotiating settlements impact my network contracts?

Retaliation for exercising audit appeal rights is prohibited. We incorporate proper legal safeguards into audit responses and settlements. Maintaining your existing contracts is always a priority.

What are the costs of legal representation in a payor audit?

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

Can your guidance help prevent future payor audits?

Absolutely. We provide tailored compliance recommendations to help healthcare providers reinforce areas prone to payor scrutiny. Proper documentation and adherence to billing and coding guidelines are critical to minimizing the risk of future audits.

Can payor audits impact my reimbursement rates or value-based contract metrics?

Potentially. Depending on the scope of the audit and the findings, your reimbursement rates or performance metrics in value-based contracts may be affected. Our specialists work to minimize any potential consequences and ensure that audit outcomes are fair and accurately reflect your practice's performance.

Health Law Alliance

Book a Free Consultation

We hold payors accountable to their audit and legal obligations, protecting your practice's revenue and reputation. Do not wait until your rights are compromised. 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.