Legal Insights

Express Scripts is targeting prior authorization Fraud, Waste & Abuse involving the use of CoverMyMeds provider accounts by pharmacies. Pharmacies and physicians beware.

In the final Part Three of a three-part series on corporate transactions, we describe important considerations around structuring the sale of a business as an "asset" sale.

DEA registration applications are receiving increased scrutiny as DEA turns its sights on providers and pharmacies to curtail controlled substance misuse and abuse. Applicants can and should take steps to ensure the registration process moves as quickly and smoothly as possible.

In Part Two of a three-part series on corporate transactions, we describe important considerations around structuring the sale of a business as a "stock" sale, including advantages and disadvantages compared to an "asset" sale.

On the heels of federal criminal investigations into OTC card usage, payors are now auditing OTC processes and imposing severe sanctions, including network termination, for non-compliance. Pharmacies should be wary of increased enforcement in this area and take steps to proactively reduce audit risk.

Insurers have bet big on Medicare Advantage, but the government is slowly cutting back. Faced with rising medical loss ratios and CMS reimbursement cuts, payors and their PBMs are planning to make up those losses by increasing pharmacy claims audits and unilateral recoupments.

Texas pharmacies are facing increasing scrutiny by the Board of Pharmacy, which is working closely with the DEA and other federal agencies, to investigate regulatory violations and Medicaid claims.

PBMs are huge companies that often use their market power in an abusive and predatory manner. This case study and successful network appeal provides an example of why experienced PBM audit defense attorneys are necessary to hold PBMs legally accountable and protect your rights.

In Part One of a three-part series on corporate transactions, we describe preliminary considerations around deal structure. In subsequent articles, we dive deeper into the advantages and disadvantages of asset sales versus stock sales.