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When is the last time you took a stand on something that you believed in? Here, at HLA, we stand up everyday for clients across the country who we believe in and who are in serious need of help, whether that be against PBMs, payors, the federal government, or some other industry giant looking to crush them and their livelihood. It's not easy, and anyone who promises specific results should not be taken at their world. With us, however, you can be assured that we will represent you fiercely at every turn. It's just who we are and what we do based on decades of experience at the highest levels of industry. Today's lawsuit is one example of that commitment.
Texas Lawsuit to Stop Optum PBM Audit Termination
PBMs like Optum have motivations behind their audits that are not always apparent. However, our founding partner, Anthony Mahajan, previously served as the Chief Compliance Officer of United Health, with oversight over both Optum and United Healthcare. We used to work for them, now we fight for you.
You can read HLA's complaint HERE, a summary of the relief requested HERE, and our legal arguments HERE. Among other claims, we allege that our client was selected for termination because Optum wanted to reverse or transfer to its internal, mail-order pharmacy claims for beneficiaries of United Healthcare plans. The lawsuit alleges that United Health is losing money on its Part C Medicare Advantage capitated plans given rising medical loss ratio, and therefore is particularly incentivized to audit and recoup on prescription claims using its corporate affiliate, Optum Rx.
Alleged Violations of Texas PBM Audit Reform Laws
We have many clients in the great State of Texas who have been targeted by Optum and other PBMs as a result of their relationship with telemedicine providers. In our client's case, the pharmacy was targeted for termination due to "mailing on a retail contract." Nonetheless, in addition to the waiver on mailing arising from the pandemic, Texas has specific PBM reform laws, enacted under Governor Abbott, that expressly prohibit payors and PBMs from barring mail-order delivery in their provider contracts.
With HLA, providers can hold PBMs like Optum accountable to their legal obligations because our PBM audit lawyers have decades of experience litigating federal and state laws.
Alleged Violations of Federal and Texas "Prompt Pay" Laws
PBMs often refuse to reimburse providers for claims that are submitted during the pendency of an audit. This results in a difficult choice for many: should you continue serving patients in good faith, or should you change course to avoid the possibility of the PBM recouping on everything owed.
However, Texas and federal laws prohibit PBMs from refusing to reimburse "clean claims" within certain time periods. These laws may also prohibit PBMs from extending the "look-back" period for claims audits. In addition, certain laws impose significant monetary penalties on PBMs who do not comply.
HLA's lawsuit alleges that Optum refused to timely reimburse the pharmacy for hundreds of thousands of dollars in clean claims even though Optum's final audit findings were far lower. If a PBM is refusing to pay reimbursement due and owing, you should understand your rights under these "prompt pay" laws.
Texas PBM Audit Attorneys Fighting for You
If your pharmacy is facing unjust termination from a PBM’s network, or other PBM audit abuses, HLA can help you level the playing field. Our PBM audit defense team has successfully resolved PBM audits across the country because we have a reputation as trial lawyers with the dedication to win.
Contact us today to learn more about how we can advocate for your rights and fight for your continued ability to serve your pharmacy patients.
Frequently Asked Questions
Can I join HLA's lawsuit against Optum Rx for PBM audit termination?
Unfortunately, PBM provider manuals contain provisions that prohibit "class actions," meaning the joining of multiple plaintiffs against a defendant in one complaint.
Am I able to file a lawsuit against Optum Rx for PBM audit violations?
Yes, you are entitled to file a lawsuit in federal or state court to hold the PBM accountable for PBM audit violations. Ultimately, however, lawsuits should be a remedy of last resort if PBM audit negotiations fail.
What are the costs associated with filing a PBM audit lawsuit?
Legal fees and expenses vary depending on the nature of the lawsuit and claims involved. Some PBM audit lawsuits may be resolved quickly, whereas others may take longer or be referred to arbitration. Finally, certain claims may be eligible for "contingent fee" arrangements, particularly if you are a specialty pharmacy with high DIR claw-backs.
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Guide independent pharmacies in recognizing and proactively managing specific behaviors and operational trends that commonly lead to PBM audits. This article will offer a detailed watchlist of PBM audit triggers and present practical, actionable steps for minimizing risks of audit findings and compliance issues.
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After the Department of Justice threatened to indict our client for involvement in an alleged $6M healthcare fraud, we stood firm and our tenacious advocacy ultimately convinced the Strike Force to decline prosecution, representing a complete win for HLA's client.
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