Favorable Result of an Audit Challenge

by Gregory J. Pepe

February 9, 2022

OptumRx, a company working with United Health Care to manage United’s pharmacy benefits for individuals insured under those plans, conducted an audit of NPM’s client in connection with some prescribing “anomalies” alleged by Optum.  Our client has its own in-house pharmacy where it dispenses many different drugs for pain management. The arrangement is beneficial for patients who are often in great pain and have disabilities. The in-house pharmacy is also a valuable integral part of the client’s business. Optum identified forty-four (44) such “anomalies.” NPM worked with the client to address each one, submitting hundreds of pages of documentation. Optum wanted to “claw back” money it had paid to the client and terminate the client as a provider in the Optum network.

We recently had a virtual hearing which included thirteen Optum representatives, three of the client’s employees, and Gregory J. Pepe of Neubert, Pepe & Monteith, P.C., who presented our client’s case.  While these appeals are not often angry shout-fests, they can be quite testy because of what is at stake, and because NPM holds literally thousands of pages of documents that make our case.  We have now received notice from Optum that it was reversing its decision to terminate the client from the network. Optum’s reversal will result in about a $1 Million decision in favor of the client.

Gregory J. Pepe healthcare law business law attorney in New Haven CT
Gregory J. Pepe

Gregory J. Pepe, founding principal, practices in the areas of commercial finance, healthcare law, alternative dispute resolution and mediation, and general business law. Attorney Pepe represents numerous physician groups, including large integrated practices, IPAs, and PHOs. He has been an advisor to many state medical societies, including the Connecticut State Medical Society regarding physician practice management issues within the context of organized medicine, and regarding initiation of litigation by medical societies against managed care companies.