Humana Audit & Investigations Defense Attorneys

Former Top Prosecutors, Federal Investigators & Government Regulators Working for You

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Don't Let Humana Push You Around - Put the Power on Your Side with Our Team

Humana audits can put significant financial and administrative strain on healthcare providers and pharmacies. With strict compliance requirements and complex audit criteria, Humana audits often lead to steep repayment demands and potential penalties. Health Law Alliance has the experience and expertise to defend providers in Humana audits, protecting your rights, minimizing financial liabilities, and preserving the integrity of your practice.

  • Strategic Audit Defense: Customized strategies to address specific areas Humana targets in audits, reducing or eliminating potential recoupments.
  • Thorough Documentation Review: Detailed analysis of your records to identify compliance issues before they escalate.
  • Experienced Legal Advocacy: Attorneys well-versed in payor audit processes, fighting for fair treatment and minimal financial impact.
  • Dispute Resolution Expertise: Skilled negotiators who challenge audit findings and defend against excessive penalties.
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    Past Experience

    Why Health Law Alliance?

    Our team is your best defense.

    Healthcare Specialty Attorneys and Consultants - Health Law Alliance specializes in healthcare law and is dedicated to defending healthcare providers and their licenses from overreach.

    Tenacious Defense - Health Law Alliance has gone after – and beaten – much bigger opponents. When faced with a seemingly daunting legal issue, our attorneys are the ones to call.

    ‍Proven Track Record - The attorneys at Health Law Alliance have a demonstrated track record of success against the most aggressive government regulators and industry behemoths.

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    FAQs

    What triggers a Humana audit?

    Humana audits can be triggered by a variety of factors, including unusual billing patterns, high-cost claims, or non-compliance with Humana’s contract requirements. Sometimes, audits are random, while other times they’re based on suspected policy violations. If you’ve received an audit notice from Humana, it’s essential to seek legal counsel to prepare an appropriate response and minimize risks.

    What consequences can I face in a Humana audit?

    The outcomes of a Humana audit can vary widely, from repayment demands to contract termination. In some cases, Humana may impose financial penalties or remove you from their network if they find significant issues. Health Law Alliance specializes in defending against these consequences, using a detailed approach to dispute findings and protect your practice’s financial health.

    How can Health Law Alliance help with a Humana audit?

    Our attorneys assist in every stage of the Humana audit process. From initial response and document preparation to challenging unfavorable findings, we provide comprehensive support. Health Law Alliance leverages extensive experience in PBM and payor audits, particularly with Humana, to protect your livelihood and ensure compliance with Humana’s complex standards.

    What steps should I take after receiving a Humana audit notice?

    Upon receiving an audit notice from Humana, start by reviewing the document to understand the audit’s scope and deadlines. Avoid responding immediately without legal advice. Health Law Alliance can help you prepare a strategic response, gather the necessary documents, and communicate with Humana on your behalf to ensure a robust defense.

    How long does the Humana audit process typically take?

    The duration of a Humana audit can vary depending on the scope, response times, and any disputes that arise. Some audits are resolved in a few months, while others can take longer if there are complex issues or negotiations involved. Health Law Alliance assists in streamlining this process, advocating for a fair resolution as efficiently as possible.

    Can Health Law Alliance help prevent future audits from Humana?

    While it’s impossible to completely prevent future audits, Health Law Alliance offers compliance support to reduce audit triggers. We help identify potential areas of vulnerability in your practice and advise on best practices to align with Humana’s audit standards, which can minimize the risk of future scrutiny.

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    01

    Understanding Humana Audit Defense

    Humana audits are part of the company's efforts to ensure compliance, prevent fraud, and recover overpayments. These audits involve thorough reviews of billing practices, prescription documentation, and compliance with Humana's specific contract terms. However, even minor errors can lead to significant financial consequences. Health Law Alliance provides experienced Humana audit defense, protecting providers from the high costs and administrative burden of these audits.

    02

    Key Laws and Regulations in Humana Audits

    Humana audits are governed by a combination of federal and state regulations, along with the terms in Humana’s provider contracts. Key regulations include:

    • False Claims Act (FCA) – This law can come into play if there are allegations of fraudulent billing to federal programs.
    • Medicare and Medicaid Billing Guidelines – For providers handling Medicare or Medicaid patients, compliance with federal billing requirements is essential.
    • Humana Contract Terms – Humana sets unique standards for prescription verification, record-keeping, and billing practices, which providers must adhere to in order to remain compliant.

    With deep knowledge of these regulations, Health Law Alliance can help you navigate the complexities of a Humana audit.

    03

    Common Issues and Challenges in Humana Audits

    Humana audits frequently identify issues in areas such as:

    • Inadequate Documentation – Missing or incomplete records can trigger repayment demands.
    • Verification Standards – Humana’s stringent verification requirements for prescriptions can lead to challenges in proving compliance.
    • Billing Discrepancies – Even minor differences between billed amounts and actual costs can be flagged for review.
    • Non-Compliance with Contract Terms – Deviations from Humana’s terms, whether intentional or accidental, often result in financial penalties.

    Health Law Alliance’s attorneys specialize in addressing these issues and challenging excessive demands, helping you protect your practice.

    04

    The Legal Process for Humana Audit Defense

    Responding to a Humana audit involves multiple steps, including:

    1. Initial Review of Audit Notice – Examine the notice to understand the specific areas of focus.
    2. Document Collection and Preparation – Gather all necessary records, including prescription and billing documentation.
    3. Legal Response Development – Work with legal counsel to prepare a thorough response to Humana’s audit findings.
    4. Dispute and Negotiation – Challenge any unjust findings and negotiate potential recoupment amounts.
    5. Compliance Review – Identify areas for improvement in internal processes to prevent future audit issues.

    Health Law Alliance provides support at each step, ensuring that your rights are protected and mitigating potential impacts on your practice.

    05

    Potential Consequences and Outcomes of a Humana Audit

    The outcomes of a Humana audit can include:

    • Repayment Demands – Humana may seek repayment for alleged overpayments.
    • Penalties and Fines – Financial penalties may be assessed for compliance issues.
    • Network Termination – Serious audit findings can result in termination from Humana’s provider network.
    • Increased Scrutiny in Future Audits – Providers with repeated issues may face more frequent audits.
    • Damage to Reputation – Negative audit outcomes can impact a provider’s reputation and business relationships.

    Health Law Alliance fights to minimize these risks and protect your practice’s financial health and standing with Humana.

    06

    How Our Firm Assists with Humana Audit Matters

    Health Law Alliance offers a range of services tailored for Humana audits, including:

    • Audit Strategy Development – We create a customized defense plan based on Humana’s specific audit requirements.
    • Record Review and Compliance Support – Our team analyzes your records to identify compliance gaps and strengthen your position.
    • Audit Dispute and Negotiation – We challenge any unjust findings and work to minimize financial penalties.
    • Preventative Compliance Advice – Beyond defense, we provide proactive guidance to reduce the risk of future audits.

    By partnering with Health Law Alliance, you gain experienced advocates dedicated to protecting your interests during Humana audits.

    government & commercial claims Auditors

    Payor & PBM Audit Companies

    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.