.avif)
Just days after we sued Optum in federal court in the Northern District of Texas, Optum immediately released approximately $250,000 in reimbursement that it had unlawfully withheld from our client for more than six months on the basis of non-existent PBM audit discrepancies. The fact that we had to sue Optum to obtain this relief serves as another example of the extent to which PBMs abuse their market position at the expense of network pharmacies.
Texas Lawsuit to Stop PBM Audit Violations is Continuing
Although Optum has now returned our client's money, we do not intend to stop there. We have filed an Amended Complaint that alleges that United Health is applying different PBM audit metrics and standards to pharmacies that service beneficiaries of United Healthcare's Part C Medicare Advantage capitated plans than other network pharmacies.
If you have been targeted for a PBM audit focused on claims for Medicare Advantage AARP members, or other United Healthcare sponsored plans, our experienced healthcare attorneys are available to defend the PBM audit.
Texas PBM Reform Permits Mail-Order Deliveries
In our case, Optum's PBM audit alleged that certain of the pharmacy's claims were invalid because they had been delivered by mail to patients located hundreds of miles away.
In Texas, however, PBM reform laws expressly forbid payors and PBMs from barring mail-order delivery. Accordingly, if you are a Texas provider and have been targeted for a PBM audit based on mail order deliveries, we can help you hold PBMs like Optum accountable to their legal obligations.
PBMs are Prohibited from Withholding Reimbursement
Many laws prohibit PBMs from refusing to reimburse "clean claims" within certain time periods. In our case, Optum withheld reimbursement due the pharmacy in violation of such "prompt pay" laws for more than six months. Once we sued Optum, it was forced to comply with the law.
Nonetheless, there may be scenarios in which a PBM is permitted by the terms of its agreements to hold funds pending completion of an audit. The extent to which a PBM may withhold reimbursement due and owing on certain claims pending an audit of other claims is highly dependent on the facts and legal obligations at play.
Nationwide PBM Audit Specialists
Although our lawsuit against Optum was filed in Dallas, Texas, our firm assists pharmacies and providers nationwide to defend PBM and payor audits. If you have been selected for a PBM audit, are appealing the results of that audit, or are facing network termination as a result of discrepant audit findings, our PBM audit defense specialists are available to help. Contact us today for a free consultation.
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.
How to Respond to an OIG Subpoena: Defense Strategies for Healthcare Providers
Receiving an OIG subpoena means your healthcare practice is under federal investigation, typically for healthcare fraud or regulatory violations. Understanding how to respond to an OIG subpoena effectively is crucial to protecting your practice.
Read More >>Provider Alert: New York Physician Indicted in Louisiana for Virtually Prescribing Abortion Medication
New York doctor indicted in Louisiana for prescribing abortion pills via telehealth, raising legal battles over state laws, shield protections, and provider risks post-Dobbs.
Read More >>DEA Announces Three New Rules Expanding Telehealth Access
This article outlines the details of the three new telehealth rules promulgated by the Drug Enforcement Agency (DEA) and their impact on telehealth providers.
Read More >>Remote Patient Monitoring: Know the Basics of Compliant Billing and Coding
In the article we outline the basics of RPM billing and coding, including which RPM services are billable by payor, the unique fraud risks associated with RPM, and best practices for providers to ensure their billing/coding procedures for RPM services are legally compliant.
Read More >>