As the largest healthcare company in the United States—and the world—United Healthcare takes a different approach than most health insurance companies. Rather than employ a third-party pharmacy benefit manager (PBM), United Healthcare handles the audit process in-house. In fact, United Healthcare regularly engages in invasive audits of the pharmacies it oversees. If United Healthcare is your pharmacy’s PBM, and you receive word of an upcoming audit, it is essential that you are prepared to defend your pharmacy’s billing practices.
Oberheiden, P.C., provides comprehensive representation to healthcare providers nationwide in United HealthCare audits. This includes audits targeting providers’ direct billings to United HealthCare, as well as audits targeting Medicare compliance. We’ve created a nationwide network of highly experienced healthcare defense lawyers and pharmacy compliance consultants who are ready to immediately intervene to ensure your United Healthcare audit goes smoothly.
The pharmacy audit defense at Oberheiden, P.C. has centuries of combined experience, and we have a proven track record when it comes to helping providers avoid liability for PBM-related sanctions and other penalties.
This comprehensive experience – which includes prior experience as healthcare fraud prosecutors and law enforcement agents – allows us to take an all-encompassing approach to defending our clients during United HealthCare audits. We can effectively and efficiently assess your pharmacy’s risk areas and execute a targeted defense strategy. Due to the complexity and high stakes of a United HealthCare audit, pharmacies facing an audit must have a knowledgeable advocate by their side. Oberheiden, P.C., can immediately fill this role.
What Triggers a United HealthCare Pharmacy Audit?
In its role as a pharmacy benefit manager, United HealthCare conducts audits of participating pharmacies to ensure their compliance under the terms of the contract they have with the insurer. United HealthCare refers to this as fraud, waste and abuse. According to United HealthCare, the purpose of an audit is to identify, correct and eliminate fraud, waste and abuse.
For example, the following are potential pharmacy violations that may raise a red flag to United HealthCare auditors:
- Acquisitions of prescription drugs through the black market;
- Billing for a brand name drug but dispensing a generic drug;
- Billing for invalid prescriptions due to lack of a legal prescriber, forgery, or false or fictitious documents;
- Billing for more fills or refills than were authorized;
- Billing multiple payers for the same prescriptions;
- Collusion with another prescriber, wholesaler or others
- Dilution of drug product provided to the patient;
- Illegal kickback schemes; and
- Improperly billing for larger pack sizes when one smaller pack size will meet the directions of the prescriber;
- Inappropriate billing of compounded drugs;
- Overbilling of the quantity prescribed;
- Providing patients with fewer pills than prescribed.
- Splitting prescriptions into multiple claims to obtain multiple dispensing fees;
- Submitting a dummy DEA/NPI number or invalid DEA/NPI numbers to obtain reimbursement;
- Using the incorrect National Drug Code;
Of course, this is not an exhaustive list. United HealthCare auditors may identify any pharmacy process as a red flag and determine it warrants a closer look.
What Does a United HealthCare Pharmacy Audit Look Like?
Once United HealthCare determines that an audit is necessary, it must provide a pharmacy with reasonable notice. Pharmacies should review their contract with United HealthCare to determine the necessary amount of notice that must be provided. Assuming that the insurer provides adequate notice, pharmacies are expected to have ample staff on hand to facilitate the audit, including assisting auditors in locating and gathering all records that are relevant to the audit.
When the auditors arrive, they will immediately request extensive documentation. United HealthCare expects that auditors will be given full access to all records. A denial of an auditor’s request may be considered a breach of the pharmacy’s contract with United HealthCare.
Some of the records and documentation that auditors may ask to review include:
- CMS10147 and other required documents and notices
- Daily prescription logs
- Fraud, waste, and abuse training logs
- Internal pharmacy compliance policies and procedures
- LEIE/EPLS verifications
- Patient profiles
- Prescriber information
- Prescription hardcopies
- Purchase invoices
- Refill information
- Signature/delivery logs
Once auditors have gathered all the data they need, they will begin a thorough review. Auditors are trained to identify even the most seemingly insignificant violation—either of state law, federal law or the terms of the pharmacy’s contract with United HealthCare. Thus, it is imperative that all records are both complete and accurate.
How an Experienced United HealthCare Pharmacy Audit Lawyer Can Help Your Pharmacy Survive an Audit
Given the burdensome compliance obligations pharmacies face when working with United HealthCare, it is essential pharmacies notified of an upcoming audit seek the advice of experienced legal counsel as soon as possible. At Oberheiden P.C., we advise and represent pharmacies throughout the United HealthCare audit process, from preparing for the audit to dealing with any fallout stemming from an unfavorable audit.
When our pharmacy compliance and audit attorneys are engaged as defense counsel during a United HealthCare pharmacy audit, the following are some of the services we provide:
A Pre-Audit Assessment of All Pharmacy Practices
From the moment we get involved in a PBM audit, Oberheiden, P.C., will assign you a pharmacy compliance and audit defense attorney. They will immediately schedule a time to meet with you to go over your pharmacy’s practices. Your United HealthCare audit lawyer will also review your existing compliance program and your pharmacy’s billing procedures. We also review the other records United HealthCare auditors may ask for. As a team, this provides us with a better idea of what to expect during the audit. Additionally, we will reach out to United HealthCare to inform the insurer that you are represented by counsel. Often, conveying this information gives auditors pause, as they know their every action will be scrutinized.
On-Site Support Throughout the Audit
Many pharmacies have never been through a PBM audit. Thus, without the assistance of a PBM audit attorney, a pharmacy is often left wondering what their rights are during the process, how to ensure the audit is conducted properly, and what can be done in the event auditors make a request that exceeds the scope of their authority. United HealthCare auditors will show up as though they are federal agents, making demands and determinations without any input from the pharmacy. However, United HealthCare auditors are contractually limited in what they can ask for. At Oberheiden, P.C., ensure a physical presence during your United HealthCare audit to ensure that auditors follow the appropriate methodology and do not make any incorrect assumptions. We will also be there to challenge any unreasonable demands made by auditors.
United HealthCare auditors are trained to look for even the most trivial violation. Indeed, United HealthCare’s auditors are a revenue-generating resource for the company, as a violation may allow United HealthCare to implement financial sanctions against a pharmacy, keeping more money in the company’s coffers. Given the incentive United HealthCare auditors have to find violations during an audit, it is common for an audit to uncover one or more violations. At the end of an audit, United HealthCare auditors may demand a recoupment, implement prepayment review, or, in cases involving more serious violations, announce the termination of the pharmacy’s contract with United HealthCare. While auditors state their findings as fact, United HealthCare’s determinations can be challenged. At Oberheiden, P.C., our PBM audit attorneys will to negotiate with United HealthCare to reduce or remove proposed sanctions.
Challenging Auditors’ Determinations in Court
Many of the issues that arise during a United HealthCare audit can be effectively resolved out of court through negotiation. However, occasionally, litigation is necessary, especially in the event of multiple or serious violations. As a team of experienced pharmacy defense litigation attorneys, Oberheiden, P.C., is ready to challenge the results of any unfavorable audit in court. United HealthCare knows that litigation is expensive and, whenever possible, prefers to avoid this additional expense. Thus, when the company realizes that defending against a lawsuit is a very real possibility, it will often reconsider its position and be more willing to engage in fair negotiations.
While much of our pharmacy defense practice is focused on guiding pharmacies through the United HealthCare audit process, Oberheiden, P.C. pharmacy compliance attorneys also work hand-in-hand with pharmacies to develop comprehensive compliance programs that can decrease the likelihood of a future United HealthCare audit or federal investigation.
Frequently Asked Questions:
Why don’t we call ourselves the “best United HealthCare pharmacy audit” lawyers?
Oberheiden, P.C., is a leading pharmacy audit defense law firm with centuries of experience assisting pharmacies through all types of PBM audits. We are confident in our ability to help pharmacies through a United HealthCare audit. However, we don’t refer to ourselves as the “best United HealthCare audit defense lawyers” for a few reasons. First, we recognize that our firm represents highly educated and sophisticated clients who are persuaded by marketing gimmicks or conclusory statements made without supporting evidence. Moreover, we believe that the term “best” is subjective and potentially misleading when used to describe an attorney’s services. Who can define what makes an attorney the “best”? And, because we take our ethical obligations seriously, we entirely refrain from making any statements that could be misleading. Regardless, for those looking for the best United HealthCare audit attorneys; we believe that our track record speaks for itself.
What should I look for in a United HealthCare pharmacy audit lawyer?
United HealthCare audits are a unique practice area that many lawyers do not have experience with. These audits are not something that all lawyers handle—even those who frequently represent pharmacies in other related matters. Thus, when it comes to selecting a United HealthCare pharmacy audit defense attorney, experience is perhaps the most important consideration. Pharmacies should identify a lawyer who has successfully handled United HealthCare audits in the past. When interviewing lawyers to help you navigate an audit, always ask the attorney about their specific experience and track record as it relates to United HealthCare audits. At Oberheiden, P.C., our pharmacy defense and compliance attorneys have centuries of experience, and many of our lawyers formerly held high-ranking positions in the federal government, enforcing pharmacy compliance. This gives Oberheiden, P.C. unique insight into pharmacy compliance obligations and how to effectively navigate a United HealthCare audit.
What are a pharmacy’s rights when undergoing a United HealthCare audit?
A pharmacy’s rights during the United HealthCare audit process depend on the state where the pharmacy operates as well as the terms of the pharmacy’s contract with the insurer. The relationship between a pharmacy and United HealthCare is defined entirely by the contract. This agreement lays out both parties’ rights and obligations and provides certain processes that must be followed throughout the audit. Generally, pharmacies have the following rights:
- United HealthCare must provide reasonable notice of the audit;
- United HealthCare must rely on a limited and clearly defined look-back period;
- United HealthCare must reimburse a pharmacy for claims that were improperly denied;
- United HealthCare must provide a pharmacy with timely notice of the audit results; and
- United HealthCare must provide explanations of any demand for recoupment.
Additionally, pharmacies have the right to challenge United HealthCare auditors’ findings as well as any sanctions imposed by the company. At Oberheiden, P.C., we help pharmacies familiarize themselves with their rights to ensure their interests remain protected throughout the audit process.
Discuss Your Upcoming United HealthCare Audit with a Pharmacy Audit Attorney at Oberheiden, P.C.
If you recently learned that United HealthCare will be auditing your pharmacy, your next move should be to call the dedicated pharmacy audit defense lawyers at Oberheiden, P.C. We offer all pharmacies an immediate and confidential consultation with a senior attorney who will answer your questions and immediately begin creating a strategic audit defense plan. You can reach Oberheiden, P.C. by calling 888-680-1745 or by completing our online contact form.