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Telehealth & Referral Arrangements Attorneys

When Telehealth and Referral Compliance Threatens Your Practice, Get Expert Help

Telehealth and referral arrangements can result in significant legal risks, including regulatory violations, patient privacy issues, and potential fraud allegations. Your approach to these areas is critical. Do not wait until your compliance is questioned.

Healthcare providers need to ensure their telehealth and referral practices adhere to complex and evolving regulations. Our founding partner was a top executive in a major healthcare organization, overseeing telehealth operations. No one understands the laws applicable to telehealth and referrals better than us. Our nationally recognized team of healthcare attorneys has decades of combined experience in telehealth and referral compliance. Put our inside knowledge and expertise to work for your practice today. If you're expanding into telehealth or managing referral relationships, act now.

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250+

TELEHEALTH & REFERRAL ARRANGEMENTS ADVISED
Past Experience
TELEHEALTH & REFERRAL EXPERTISE

Healthcare Fraud Defense Lawyers

Our telehealth and referral compliance team has helped clients implement compliant telehealth programs, structure proper referral arrangements, and defend against regulatory scrutiny.

We provide expert legal advice tailored to your specific circumstances using our knowledge of telehealth regulations and referral law pitfalls. As lawyers, we leverage federal and state law to protect your rights and ensure compliance.

When your practice's future and reputation are at stake, our team of experienced healthcare attorneys is your trusted advisor.

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
TELEHEALTH & REFERRAL CASE STUDIES
PBM Case
Studies

Recent Telehealth & Referral Successes

Learn directly from healthcare providers who successfully implemented telehealth programs and compliant referral arrangements—with our assistance, they expanded their practices while maintaining regulatory compliance.
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TELEHEALTH 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 your telehealth goals or referral arrangement needs, gather background information, and identify potential compliance risks.
02

Detailed Compliance Analysis

Our team conducts a thorough analysis of your current or proposed telehealth/referral practices to identify areas of concern and opportunities for improvement.
03

Legal & Regulatory Review

We provide a comprehensive legal review, ensuring your telehealth program or referral arrangements comply with all applicable federal and state laws and regulations.
04

Implementation & Ongoing Support

We guide you through the implementation of compliant telehealth programs or referral arrangements, providing ongoing support to address evolving regulatory requirements and operational challenges.
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FAQ

Frequently Asked Questions

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

Initially, we'll need information about your current or planned telehealth services, any existing referral arrangements, and relevant operational documents. As we develop your compliance strategy, additional documentation may be requested. We will provide specifics on supporting materials.

What recourse exists if a telehealth platform violates patient privacy?

We can help you address any privacy breaches, including necessary reporting and corrective actions. We also assist in reviewing and negotiating vendor contracts to ensure proper safeguards are in place.

Do telehealth regulations vary by state?

Yes, telehealth laws and regulations can vary significantly by state. We help you navigate these differences, especially if you're providing services across state lines.

Can you help if my telehealth services or referral arrangements are questioned by regulators?

Yes. We provide robust defense and advocacy services for healthcare providers facing regulatory scrutiny of their telehealth or referral practices. Our goal is to resolve issues efficiently and protect your practice.

Will implementing telehealth services impact my existing practice operations?

While telehealth can enhance your practice, it requires careful integration. We help ensure that your telehealth services complement your existing operations and comply with all relevant regulations.

What are the costs of legal representation for telehealth and referral compliance?

We offer flexible fee arrangements based on the scope of representation required and the complexity of your telehealth or referral needs. Early involvement allows us to proactively address compliance issues, making our services more cost-effective.

Can your guidance help prevent future regulatory issues with telehealth and referrals?

Absolutely. We provide tailored compliance recommendations to help you stay ahead of evolving telehealth and referral regulations. Proper documentation and ongoing compliance monitoring are critical to preventing regulatory issues.

How can I ensure my referral arrangements don't violate anti-kickback laws?

We help structure your referral arrangements to comply with anti-kickback laws and other relevant regulations. Our expertise ensures that your arrangements are both legally compliant and beneficial to your practice.

Health Law Alliance

Book a Free Consultation

We help healthcare providers navigate the complex landscape of telehealth and referral compliance. Don't wait until your practices are questioned. 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.