Audits

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.

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.

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.

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.

 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.

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.

For DME suppliers, a letter from a Unified Program Integrity Contractor (UPIC) is not a routine records request; it's a high-stakes fraud investigation that can trigger payment suspensions and threaten your company's survival. Our latest article explores the aggressive tactics of these powerful auditors, identifies the specific CMS contractors that monitor and police the industry, and details the common billing patterns that can place your business directly under their microscope. Read our guide to understand the immense financial risks of a UPIC audit and learn how to prepare for and respond to this critical business threat.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.