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Audits

Guidance for New Entrants on Navigating PBM Audit Complexities

New pharmacy owners face complex PBM audit requirements that demand strict documentation, accurate claims, and ongoing compliance. Establishing strong recordkeeping systems and proactive audit readiness can help prevent costly recoupments and protect long-term network participation.

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How Pharmacies Can Challenge Unfair PBM Audit Findings

PBM audits can leave pharmacies facing exaggerated findings, steep recoupments, and even network termination. With the right strategies and legal support, pharmacies can successfully challenge unfair results and protect their business.

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Top Red Flags That May Trigger a PBM Audit

PBM audits can be disruptive, costly, and often triggered by high prescription volumes, dispensing irregularities, or claim activity. Pharmacies can reduce risks through strong documentation, compliance, and legal support to challenge unfair findings and protect network status.

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Approaching the Telehealth Policy Cliff: Medicare Telehealth Flexibilities to Expire Next Week

Without further congressional action, COVID-19 era telehealth flexibilities are set to expire on September 30, 2025. Read more to learn about what’s set to change and key guidance for telehealth providers to prepare to adapt to pre-pandemic coverage rules.

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Standing Up for Pharmacies: How HLA Fought and Reversed Optum’s Termination of a New York Pharmacy

 In a recent victory, our attorneys at Health Law Alliance achieved a full reversal of Optum’s termination of a New York pharmacy. Read about how HLA fought tirelessly to rebut Optum’s allegations and how Health Law Alliance can defend your pharmacy from an unjust termination.

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DME Supplier Defense Attorneys' Guide to the Different Types of Government Audits

For DME suppliers, a notice from CMS can be daunting, especially when you're trying to figure out the difference between a TPE, SMRC, and UPIC. Each of these audit contractors has a different mission, scope, and level of risk for your business. Our latest blog post breaks down the "alphabet soup" of CMS audits, explaining what each entity does, what they look for, and how you should respond when they contact you. Protect your business by understanding who is on the other side of the audit.

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Building an Audit-Proof Documentation System for Your DME Supplier Business

In a CMS audit, your documentation is your only defense. A missing signature or an incomplete progress note can lead to a costly overpayment demand. Is your record-keeping system truly protecting you? This article provides a blueprint for creating an audit-proof documentation system. We cover everything from intake checklists to monthly note requirements for wound care supplies, helping you ensure every claim is fully supported and ready for scrutiny.

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DOJ Files False Claims Lawsuit Against Nationwide Specialty Wound Care Provider

The U.S. Department of Justice has filed a civil action against Vohra Wound Physicians Management, alleging various schemes to submit false claims for payment to Medicare. Learn more about the ongoing lawsuit and how Health Law Alliance supports wound care providers to avoid legal scrutiny.

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Triumph Over Optum: HLA’s Tenacious Advocacy Reverses Optum’s Termination of a Texas Pharmacy

Health Law Alliance successfully reversed Optum’s termination of a Texas pharmacy from its network, protecting the pharmacy from severe financial and reputational damage. Our healthcare attorneys used strategic legal expertise and negotiations to overturn the decision, ensuring the pharmacy could continue serving patients. This victory highlights our dedication to strong advocacy and proven results.

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Enforcement of Arbitration Clauses in PBM Network Agreements: A Guide for Pharmacy Owners

This article explains arbitration clauses in Pharmacy Benefit Manager (PBM) network agreements, outlining when these clauses can be enforced and how they affect dispute resolution for pharmacies.

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HLA Convinces Optum to Reverse PBM Audit Termination

Health Law Alliance is pleased to announce that Optum recently agreed to reverse its network termination of a Texas pharmacy client despite significant claim discrepancies based on inventory shortages, patient denials, and other alleged violations of the terms and conditions of the Provider Manual and network enrollment agreements.

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HLA's Lawsuit Against Optum Achieves Return of Hundreds of Thousands of Dollars in Withheld Reimbursement

Health Law Alliance's lawsuit against Optum has resulted in the immediate release of hundreds of thousands of dollars in reimbursement that Optum unlawfully refused to release to our client prior to being sued.

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HLA Attorney Anthony Mahajan Wins Dismissal of False Claims Lawsuit Against Oncology Dispensing Practice

Health Law Alliance's Anthony Mahajan is pleased to announce the complete dismissal of a lawsuit brought on behalf of the federal government against a cancer care provider for the submission of false Medicare claims for oncology drugs.

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HLA Files Emergency Texas Lawsuit Against Optum PBM Audit Termination

Health Law Alliance announces the filing of an emergency lawsuit in federal court for the Northern District of Texas, Dallas Division, to stop Optum's termination of an independent pharmacy that dispensed medications on telemedicine prescriptions and force Optum to comply with federal and state "prompt payment" laws that prohibit withholding of reimbursement.

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Pharmacy Benefit Managers (PBMs) Face Possible FTC Lawsuit

The Federal Trade Commission (FTC) plans to sue the top Pharmacy Benefit Managers (PBMs) for anti-competitive practices, including influencing drug prices and favoring their own networks, which disadvantage independent pharmacies and raise prescription drug costs.

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Victories Against Optum Rx: Protecting Pharmacy Clients Nationwide

Health Law Alliance has successfully challenged Optum Rx's termination decisions for numerous pharmacies, ensuring they can continue to operate and serve their communities. These victories highlight the firm's expertise in healthcare law and its dedication to protecting pharmacy clients from unjust PBM actions.

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