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pharmacy compliance pharmacy audit appeals lawyers

June 30, 2020
What The Pharmacy Audit Appeal Entails
Pharmacy compliance is an imperative necessity required to be met by all pharmacy entrepreneurs. Failure to comply with the rules, the pharmacy risk incurring hefty fines or even end up losing their licenses.

At times pharmacies may find themselves on the wrong side of the law due to unintentional mistakes. For instance, an overpayment error caused by incorrect coding can be the onset of the misfortune.

If the provider is not aware of the wrong coding, and it goes unnoticed for several months, it can result in an enormous overpayment. Such overpayment may attract auditor’s attention leading to substantial penalties.

Auditors are employed by specific medical boards according to the laws of the State. The auditors conduct prescription drug audits of participating pharmacies as well as verifying the billing processes.

The following are some of the crucial documents that the auditors check to affirm if the pharmacy is compliant with the law.

• A valid pharmacy license and it should be up to date
• The purchase records of the drugs
• Invoices
• Prescription records
• Purchase record and documents review
• Signature logs (Electronic or manual)

How Is The Audit Conducted?

The audit team reviews the prescription record and other data such as invoices to determine over-payments or any fraudulent activity. The audit will then assign an independent reviewer to perform the data analysis and validate the findings.

If the audit outcome verifies that the pharmacy did not comply with the rules, they are then sent notification of an improper payment (NIP).

Procedure to Follow If You Receive a Notification of Improper Payment

As soon as the pharmacy receives an audit report detailing any adjustments of payments, it should be noted as a red flag. The pharmacy managers will need to hire an experienced lawyer who will guide them on ways to file for appeals.

There are three levels of appeal;

• The attorney can file a request for reconsideration, which must be submitted not later than 60 days from the date on the Notice of improper payment (NIP)

• If the appeal is not successful, you ought to file for the CMS (Center for Medicare services) hearing review within 30days from the date of the first reconsideration verdict

• The third level of appeal involves requesting CMS (Center for Medicare services) administration review within 30 calendar days from the last CMS hearing decision

It should be noted that the specific timelines differ according to States. However they should be strictly followed, failure to that the case may not be viable for hearing.

To apply for the appeal process, the pharmacy will need to include appropriate documentation to support the appeal as well as the audit reference number.

If the auditor discovers instances fraud or false claims which have been submitted, the pharmacy owner could be charged with fraud under the false claims act.

Additionally to the criminal penalties, the pharmacy could also be excluded from Medicare programs. Lack of participating in such programs can lead to extreme difficulty in maintaining the pharmaceutical business.

Why Do You Need Legal Presentation?

Losing an appeal can be devastating to any pharmacy owner. That is why it is beneficial to engage with experienced lawyers such as the NYC criminal lawyers before taking any legal step.

The NYC attorneys can represent your pharmacy during the litigation and challenge unfavorable audit determination. The lawyer will advise you to collect valuable information, which may help build a good case. They can argue in your defense that you did not intend to commit the crime.

If found guilty with fraud, penalties are given regarding the severity of the error. The board of medical practitioners will classify the crime as either minor or severe. For minor offenses in most states, one is lightly fined.

However, if the pharmacy is declared to have committed weighty fraud crimes, the owner and the associates will be heavily fined or serve a jail term.


In addition to legal representation, NYC criminal lawyers can also help develop and implement a comprehensive compliance program that will protect your pharmacy in the event of an audit. Feel free to contact us any time you need legal representation.



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