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Express Scripts Pharmacy Audit Defense

If Express Scripts is your pharmacy benefit manager (PBM) and you are being audited, you need to be prepared for an invasive inquiry. Our pharmacy defense lawyers and compliance consultants can deal with Express Scripts for you and protect you against steep penalties.

Is Express Scripts your pharmacy benefit manager (PBM)? If so, your pharmacy is subject to being audited on a regular basis. Express Scripts routinely sends auditors to participating pharmacies, and these auditors conduct invasive inquiries focused on uncovering fraudulent billings and other compliance violations.

Express Scripts Audits Can Lead to Severe Consequences

If your pharmacy is being audited by Express Scripts, there is a lot you need to know. For example, in order to be considered fraudulent, an insurance billing does not have to be intentionally wrong. Even honest mistakes resulting from simple human error will be classified as fraudulent, and all fraudulent billings have the potential to lead to retraction demands, claim denials, pre-payment review, and other penalties.

How can Express Scripts impose these penalties? It has the right to do so under your PBM contract. When your pharmacy agreed to sign on with Express Scripts, it agreed to undergo periodic audits—and to face the penalties Express Scripts imposes based upon its own independent determinations.

This is just one example of numerous issues that can lead to problems for pharmacies during Express Scripts audits. As a result, if your pharmacy is being audited, it is important that you hire experienced defense counsel promptly.

Pharmacy Compliance and Defense Lawyers for Express Scripts Audits

At Oberheiden P.C., we represent pharmacies across the country in Express Scripts audits. Our lawyers include former federal prosecutors who handled pharmacy fraud cases on behalf of the U.S. Department of Justice (DOJ), and our pharmacy compliance consultants include former senior agents with the U.S. Drug Enforcement Administration (DEA). We are intimately familiar with the issues that come up during federal government and PBM pharmacy audits, and we have had significant success helping pharmacies, pharmacy owners, and pharmacists-in-charge avoid substantial penalties for allegations of billing fraud and other compliance violations.

5 Fast Facts about Express Scripts Pharmacy Audits

1. Express Scripts Pharmacy Audits Can Have Severe Repercussions

We touched on this already, but it bears repeating: If Express Scripts finds evidence that your pharmacy has billed its payors improperly—or if your pharmacy cannot demonstrate that its billings are compliant—the consequences can be significant.

2. There Are Numerous Issues That Can Lead to Problems During an Express Scripts Pharmacy Audit

Broadly speaking, the purpose of an Express Scripts audit is to identify billing errors. However, under the umbrella of “billing fraud,” there are numerous issues that can lead to problems for pharmacies. Some examples of these issues include:

  • Using incorrect billing codes
  • Submitting false or inaccurate billings
  • Double-billing and phantom billing
  • Inadequate documentation of medical necessity for prescriptions and refills
  • A high volume of cash payments
  • Regular dispensing of high-risk drugs or drug combinations

3. Pharmacy Auditors Make Assumptions and Mistakes

While some auditors are very good at what they do, faulty assumptions and mistakes during pharmacy audits are common. From drawing false links between correlating events to applying incorrect codes and making miscalculations, there are various types of issues our lawyers will examine to ensure that the outcome of your Express Scripts pharmacy audit is valid.

4. You Do Not Have to (and Should Not) Simply Wait Until Express Scripts Completes Its Audit

When facing an Express Scripts audit, you can – and should – play an active role in the process. By engaging experienced defense counsel to represent your pharmacy during its Express Scripts audit, you can avoid unnecessary problems, and you can minimize any negative outcomes to the fullest extent possible.

5. Disputing Issues During an Audit Can Be Far More Efficient than Fighting an Unfavorable Final Determination

While there are ways to challenge the outcome of a pharmacy audit, it will usually be far more efficient to engage with Express Scripts’ auditors during the process in order to avoid the need to challenge the result. While it is not always possible to prevent undesirable outcomes, we have had significant success protecting our pharmacy clients during the audit process.

Read more about ZPIC/UPIC audits.

Put our highly experienced team on your side

Dr. Nick Oberheiden
Dr. Nick Oberheiden



John W. Sellers
John W. Sellers

Former Senior Trial Attorney
U.S. Department of Justice

Local Counsel

Joanne Fine DeLena
Joanne Fine DeLena

Former Assistant U.S. Attorney

Local Counsel

Joe Brown
Joe Brown

Former U.S. Attorney & Former District Attorney

Local Trial & Defense Counsel

Amanda Marshall
Amanda Marshall

Former U.S. Attorney

Local Counsel

Aaron L. Wiley
Aaron L. Wiley

Former Federal Prosecutor

Local Counsel

Roger Bach
Roger Bach

Former Special Agent (OIG)

Michael Koslow
Michael Koslow

Former Supervisory Special Agent (FBI)

Chris Quick
Chris Quick

Former Special Agent (FBI & IRS-CI)

Kevin M. Sheridan
Kevin M. Sheridan

Former Special Agent (FBI)

Ray Yuen
Ray Yuen

Former Supervisory Special Agent (FBI)

Dennis A. Wichern
Dennis A. Wichern

Former Special Agent-in-Charge (DEA)

10 FAQs with Our Senior Pharmacy Defense Lawyers and Compliance Consultants

Q: Does Express Scripts target specific pharmacies with its audits?


Yes and no. While Express Scripts audits all pharmacies for which it serves as PBM, it may choose to specifically target pharmacies with which it has had issues in the past.

Q: What should I do if Express Scripts is auditing my pharmacy?


If Express Scripts is auditing your pharmacy, it is important that you engage defense counsel promptly. When you engage Oberheiden P.C. to assist with your Express Scripts audit, our pharmacy defense lawyers and compliance consultants will:

  • Collect and review all pertinent records
  • Conduct an independent assessment of any potential liability
  • Advise your pharmacists, technicians, and billing personnel on how to handle the audit
  • Communicate with Express Scripts’ auditors on your pharmacy’s behalf
  • Challenge auditors’ assumptions and mistakes during the audit
  • Assert all available defenses to alleged billing violations and other compliance issues
  • Work diligently to secure a favorable outcome that avoids liability

Q: When should I engage defense counsel?


We strongly recommend engaging defense counsel as soon as you learn that Express Scripts is auditing your pharmacy. There are several steps involved in executing an effective audit defense strategy, so it is important that you speak with defense counsel about your pharmacy’s audit right away. At Oberheiden P.C., we have local counsel in cities around the country, and we can begin assembling your defense as soon as you engage us to represent your pharmacy.

Q: How can I prove that my pharmacy’s insurance billings are compliant?


One of the most-effective ways to avoid liability during an Express Scripts pharmacy audit is to demonstrate compliance through the production of your pharmacy’s existing documentation. If your pharmacy can affirmatively demonstrate compliance with the records it has on hand, this will usually lead to a favorable, and relatively efficient, result.

However, before providing billing and other records to Express Scripts, you need to have a clear understanding of all of the implications of the records’ contents. This is why we conduct an upfront assessment on behalf of our clients before we make any decisions about how to deal with Express Scripts directly.

Q: Will Express Scripts only be examining my pharmacy’s billing records?


No, and this is an important issue that often gets overlooked by pharmacy owners and pharmacists-in-charge. While your pharmacy’s billing records will be a central focus of the audit, they will not be the only focus. During an Express Scripts audit, your pharmacy may also be asked to provide records such as:

  • Copies of contracts with prescribing physicians
  • Copies of contracts with third-party billing administrators and other vendors
  • Purchase records and invoices
  • Prescription drug inventory records
  • License and registration documentation
  • Signature logs
  • Compliance policies and procedures

Q: What if I don’t have all of the documentation Express Scripts is asking for?


If your pharmacy does not have documentation requested by Express Scripts auditors, you will need to work with your pharmacy’s defense counsel in order to determine how to proceed. While this is not necessarily an issue that will lead to liability, it is considered a major “red flag,” and it is an issue that you will need to address proactively during the audit process.

Q: Should I allow Express Scripts to speak with my pharmacists, technicians, and billing staff?


Generally speaking, all communications with Express Scripts should be handled by your pharmacy’s legal counsel, unless your pharmacy’s legal counsel advises otherwise. There may be limited circumstances in which it is appropriate for pharmacy personnel to communicate with Express Scripts’ auditors directly, but before doing so they should discuss the risks involved with the pharmacy’s counsel.

Q: What if I use a third-party billing administrator?


Using a third-party billing administrator does not immunize pharmacies from liability for billing mistakes. From the PBM perspective, pharmacies remain directly liable for their billings regardless of whether they handle their billings in-house or utilize the services of a third-party vendor.

Q: What if my pharmacy bills Medicare Part D?


Express Scripts offers a prescription drug plan through a contract with the Centers for Medicare and Medicaid Services (CMS), which it refers to as Express Scripts Medicare®. If your pharmacy bills Medicare Part D through Express Scripts, not only will Express Scripts review your Part D billings during its audit, but any issues that come up could also lead to scrutiny by CMS or the U.S. Department of Health and Human Services’ Office of Inspector General (DHHS-OIG).

Q: Why should I choose Oberheiden P.C. for Express Scripts pharmacy audit defense?


At Oberheiden P.C., we have extensive experience and a proven record of success defending pharmacies in audits, inspections, and investigations nationwide. Our pharmacy defense lawyers and compliance consultants include former pharmacy fraud prosecutors and senior DEA agents, and we are intimately familiar with the risks, issues, and procedures involved in defending against Express Scripts audits.

Speak with a Pharmacy Defense Lawyer or Compliance Consultant at Oberheiden P.C.

Is Express Scripts auditing your pharmacy? If so, we encourage you to contact us promptly for a complimentary case assessment. To speak with one of our senior pharmacy defense lawyers or compliance consultants in confidence, call 888-680-1745 or inquire online now.

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  • Former Department of Justice Trial Attorneys
  • Former Federal Prosecutors, U.S. Attorney’s Office
  • Former Agents from FBI, OIG, DEA
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