Prime Therapeutics Pharmacy Audit Defense Attorneys - Oberheiden, P.C.
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Prime Therapeutics Pharmacy Audit Defense

Is Prime Therapeutics your pharmacy benefit manager (PBM)? Are you facing an audit? If so, you need experienced Prime Therapeutics Audit Defense Attorneys on your side.

Like all pharmacy benefit managers (PBMs), Prime Therapeutics conducts audits to confirm that its contracted pharmacies are complying with the law and the terms of their PBM contracts. These audits are invasive and extremely detailed, and the goal is to identify any and all mistakes that may justify recoupments (or “retractions”) for Medicare or private payors. When facing Prime Therapeutics audits, pharmacies must defend themselves effectively, and they must rely on the advice of experienced pharmacy audit defense counsel.

At Oberheiden P.C., we help pharmacies avoid retractions and other penalties in PBM audits. Our lawyers and pharmacy consultants have centuries of combined experience, and we have a proven record of success protecting our clients against unwarranted and unnecessary consequences.

When facing a Prime Therapeutics audit, it is imperative to take an informed, proactive, and strategic approach. Prime Therapeutics’ auditors follow a detailed list of “Pharmacy Audit Recovery Guidelines,” and they are instructed to recover any payments that appear to be illegitimate or not supported by adequate documentation. This last point is crucial, because it means that during a Prime Therapeutics audit the question is not whether your establishment is actually in pharmacy compliance, but whether you can prove that your pharmacy’s billings are compliant.

Issues that Can Lead to Retractions and Other Penalties in Prime Therapeutics Pharmacy Audits

Prime Therapeutics has established a comprehensive set of “Pharmacy Audit Recovery Guidelines” for audits involving most payors, and it has established a separate set of guidelines for audits targeting Medicare Part D compliance. Both of these sets of guidelines are available online:

These guidelines are extremely detailed, and they list the specific types of errors that can justify retractions, describe the amount that can be recovered, and state what documentation pharmacies can use to appeal retraction demands. Here are some examples from of the types of issues that can lead to trouble for pharmacies during Prime Therapeutics audits:

  • Dispense-As-Written (DAW) 1 Error: “Pharmacy dispensed a multisource brand name medication with a DAW code of 1 when the prescription order does not indicate the prescriber ordered brand name only.”
  • DAW 2 Not Documented: “Pharmacy dispensed a multisource brand name medication with a DAW code of 2 when the documentation does not indicate the patient requested brand name only.”
  • Billing Error – Quantity Submitted with Wrong Unit of Measure: “The pharmacy submitted an incorrect metric quantity for this package, resulting in an overpayment.”
  • Billing Error – Medication Indicated as Compound: “A non-compound claim was incorrectly flagged as a compound when submitted, resulting in higher payment.”
  • Ineligible Compound or Ingredient: “Compound does not meet Part D criteria of an eligible drug.”
  • Invalid Override Code: “The pharmacy overrode a claim without the documentation supporting the reason for override.”
  • No Prescription Order Provided: “The pharmacy did not provide a copy of the prescription order as requested during the audit process.”
  • Incorrect Location Code: “The pharmacy billed a LTC location code, but the prescription was dispensed as a retail prescription to a member who does not reside in a Long Term Care Facility.”
  • Claim Ineligible for Medicare Part D: “The pharmacy billed a claim to Part D when the member resided in a Long Term Care Facility under a qualified Part A stay.”
  • Incorrect National Drug Code (NDC) Submitted: “Pharmacy system documentation indicates a different NDC was dispensed than was billed.”
  • Invalid Origin Code: “The origin code billed by the pharmacy does not match the prescription documentation.”
  • Excessive Quantity Dispensed: “The quantity dispensed by the pharmacy exceeds the benefit plan amount.”
  • No Proof of Delivery Confirming Receipt: “Acceptable proof of delivery includes signature logs, delivery logs, or computerized transaction logs.”
  • Prescription Splitting: “The pharmacy billed partial quantities in one month instead of billing a one month supply, resulting in excess dispensing fees.”
  • Quantity Dispensed Exceeds Prescription Order: “The total quantity dispensed over the course of dispensing this prescription exceeds the total quantity authorized by the original prescription order.”

How Pharmacies Can Prepare for a Prime Therapeutics Recovery Audit

As you can see, the range of errors that will be subject to review during a Prime Therapeutics audit is extremely broad—and this list is nowhere near exhaustive. As a result, when notified of an upcoming audit, pharmacies must prepare thoroughly. This involves:

1. Locating All Pertinent Documentation

From drug ordering records to electronic prescriptions and refill authorizations, there are numerous forms of documentation that will need to be made available to Prime Therapeutics’ auditors during a pharmacy audit. Pharmacies must ensure that they have all documentation on hand that will be required in order to substantiate their billings to Prime Therapeutics’ auditors.

2. Conducting an Internal Assessment

With the necessary documentation on hand, pharmacies should conduct an internal assessment to determine whether there are any issues that are likely to be discovered during Prime Therapeutics’ audit. If there are, these issues should be addressed appropriately, including (but not limited to) remedying any systemic issues that have resulted in repeated or ongoing violations.

3. Preparing Any Necessary Defenses

Even if your pharmacy is fully compliant, escaping a Prime Therapeutics audit without retraction liability will require an effective defense. If there are issues to address, it will be necessary to determine the most appropriate way to approach these issues during the audit. While it can be beneficial to affirmatively disclose known issues at the beginning of an audit in some cases, pharmacies must be extremely careful to avoid unnecessarily disclosing information that could lead to retractions and other penalties.

4. Developing an Audit Response Plan

Opening the doors to Prime Therapeutics’ auditors and letting them do their job is not an audit response plan. In order to mitigate their liability risk pharmacies must play an affirmative and proactive role in the process. To this end, pharmacy personnel should be instructed on what to do (and, more importantly, what not to do) while the audit is ongoing, and there should be prescribed steps for responding to allegations of errors and overbillings.

5. Strategizing with the Pharmacy’s Audit Defense Counsel

In order to take each of these steps effectively and in the most efficient way possible, pharmacies should engage audit defense counsel as soon as they learn that they are being audited by Prime Therapeutics. At Oberheiden P.C., our lawyers and pharmacy consultants work with our clients’ owners and pharmacists-in-charge to develop defense strategies and audit response plans designed to quickly secure favorable outcomes. If your pharmacy is facing a Prime Therapeutics audit, you do not have time to waste, and we encourage you to contact us promptly for a free initial consultation.

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)

FAQs: What Do Pharmacies Need to Know about Prime Therapeutics Recovery Audits?

Q: Why is Prime Therapeutics auditing my pharmacy?


Prime Therapeutics audits all pharmacies with which it contracts to provide pharmacy benefit management services. It has the right to conduct audits under the terms of its PBM contract, and it has the obligation to audit pharmacies under the terms of its agreements with the Centers for Medicare and Medicaid Services (CMS) and private payors.

Q: What are the potential consequences of a Prime Therapeutics recovery audit?


In most cases, pharmacies that are accused of overbilling Medicare or other payors following a Prime Therapeutics audit will face retractions, or recoupment of the allegedly overbilled amounts. However, like other PBMs, Prime Therapeutics offsets future payments, denies pending claims, places pharmacies on “corrective action plans,” and takes other punitive measures as well. In egregious cases, Prime Therapeutics can terminate pharmacies’ PBM contracts, and the company may even refer pharmacies to CMS or another agency for a federal pharmacy fraud investigation.

Q: What if I disagree with Prime Therapeutics’ auditors’ conclusions?


If you disagree with Prime Therapeutics’ auditor’s conclusions following an audit, you can appeal the outcome directly with Prime Therapeutics. The company’s audit guidelines identify the types of documentation that pharmacies can use to submit appeals, and following the requisite appeal procedures will often be necessary. If these efforts are unsuccessful, our attorneys may be able to negotiate for a favorable resolution, and we can institute formal legal proceedings if necessary.

Q: Why should I choose Oberheiden P.C. for Prime Therapeutics audit defense?


Our firm has a proven record of success defending pharmacies and other healthcare entities in audits and investigations. This includes Prime Therapeutics and other PBM audits as well as matters involving CMS, the U.S. Drug Enforcement Administration (DEA), and other federal agencies. With past experience working for these agencies, our lawyers and consultants have a comprehensive understanding of pharmacies’ compliance obligations, and we can use our knowledge to protect you and your pharmacy.

Speak with a Prime Therapeutics Audit Defense Attorney at Oberheiden P.C.

If you need legal counsel for a Prime Therapeutics recovery audit, contact us now for a free initial consultation. Call 888-680-1745 or send us your contact information to speak with one of our experienced pharmacy defense lawyers or compliance consultants in confidence.

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