Legal Insights

Following a PBM audit that uncovered a $6.5 million billing discrepancy, federal prosecutors opened an investigation. After HLA was retained, the U.S. Attorney's Office for the Eastern District of Pennsylvania agreed to a $2.5 million civil settlement in which the Owner denied all wrongdoing.

Health Law Alliance has successfully challenged OptumRx'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.

HLA's Nancy Coffey, a former government official and healthcare expert, has been appointed to serve a three-year term as an independent pharmacy monitor for the Commonwealth of Massachusetts.

PBM audits may result in collateral consequences, including licensing and disciplinary proceedings. In this case, HLA's experienced defense attorneys successfully convinced the State Board to decline further investigation, effectively resolving the matter at an early stage.

Providers need to know their rights when it comes to investigations and audits by CMS UPIC contractors, such as SafeGuard and Qlarant. These investigators are private citizens, with no more authority or power of law than anyone else. Yet, they often employ traditional law enforcement techniques. Don't be fooled.

The federal government continues to bring enforcement actions relating to false prior authorizations given the high-priced medications typically involved. In this case involving Walgreens, we take a deeper dive into potential theories of liability and the use of civil investigative demands and subpoenas in healthcare fraud cases.

Department of Justice prosecutors continue to file numerous cases against pharmacies and their owners for inventory shortfalls and other discrepancies. These cases arise out of referrals by government contractors following a pharmacy audit, and often involve severe potential consequences.

Based on a recent announcement, the federal government (HHS-OIG) will be prioritizing audits of pharmacy claims in 2024. This further signals that pharmacy audits from all angles are on the rise.

PBMs are increasingly terminating pharmacies for minor infractions of the provider manuals or network enrollment forms. These terminations are contrary to the PBM's obligations under law and the parties' agreements, and may have collateral consequences if the underlying allegations involve wrongdoing. In this case, we profile the steps that led to a successful network reinstatement for an Illinois pharmacy.