Dentaquest Audit

Nationally Recognized Healthcare Defense Law Firm Provides Comprehensive Representation During Dentaquest PBM Audits

**Attorney Lynette Byrd**
Dentaquest Audit Team Lead
Contact Lynette

envelope icon — **Attorney Lynette Byrd**
Dentaquest Audit Team Lead
Contact Lynette

**Deborah Zarifian**
Dentaquest Audit Team Consultant
Former FBI Special Agent
Registered Pharmacist (CT)

Dentaquest is a pharmacy benefit management company specializing in oral healthcare plans. The company manages dental benefits for more than 30 million people, working with more than 80 oral healthcare centers across six states. In its role as a PBM, Dentaquest regularly conducts burdensome audits of participating pharmacies. If Dentaquest is your PBM and you recently learned that you will be subject to a PBM audit in the near future, it is imperative that you contact an experienced pharmacy audit defense law firm for immediate assistance. Any PBM audit, including Dentaquest audits, present very high stakes and most pharmacies are unfamiliar with their rights and obligations during an audit. An experienced Dentaquest pharmacy audit lawyer can help pharmacies navigate the process, increasing the likelihood of a positive outcome.

At Oberheiden, P.C., our dedicated healthcare defense lawyers maintain an active PBM audit practice. Our team is highly experienced in representing pharmacies in PBM audits and can help pharmacy owners protect their interests through this complex process. Several of our senior attorneys previously worked in high-ranking positions with various federal government entities, including the Health and Human Services Office of Inspector General and the Drug Enforcement Administration, providing us with unrivaled knowledge and experience in pharmacy regulations. Regardless of whether your audit is scheduled for a month away or tomorrow, our Dentaquest PBM audit lawyers are available to intervene immediately.

What Is a Dentaquest PBM Audit?

As a pharmacy benefit manager, Dentaquest acts as the intermediary between the insurance company and the pharmacy. The insurance company pays Dentaquest to administer the pharmacy benefits, and as a result, Dentaquest performs a variety of other related services, including:

Developing and maintaining lists of covered medications;
Using their bulk purchasing power to negotiate rebates and discounts from drug manufacturers; and
Contracting directly with pharmacies to reimburse the pharmacy for drugs dispensed to patients.

Thus, a pharmacy is not actually compensated by the insurance company but by Dentaquest. One of Dentaquest’s responsibilities under its agreement with an insurance company is to perform audits of participating pharmacies.

When Dentaquest initiates an audit of a pharmacy, it’s called a PBM audit. PBM audits are not subject to significant federal oversight, leaving any regulation up to individual states. Thus, PBMs such as Dentaquest operate under a sort of veil of secrecy, putting much of the PBM audit process behind the curtains. However, based on previous audits and other available information, it is known that PBM audits typically target the following types of violations, most of which stem from billing mistakes and the requirement that a pharmacy maintains comprehensive records:

Accepting prescriptions written by excluded providers
Billing for unapproved drugs
Compound drug billing
Failure to create or maintain records
Falsification of records
Filling illegitimate prescriptions
Intentional and unintentional billing and coding errors
Invoice shortages
Licensing violations
PBM contract fraud
Telemedicine violations

Because PBM audits are only regulated on the state level, auditors tend to carry an air of authority as though they were federal regulators. However, that is not the case. Dentaquest’s right to conduct an audit stems not from any law or regulation but from the PBM contract it entered with the pharmacy.

Dr. Nick Oberheiden

Founder

Attorney-at-Law

Lynette S. Byrd

Former DOJ Trial Attorney

Partner

Brian J. Kuester

Former U.S. Attorney

Hon. Kevin McCarthy

55th Speaker, U.S. House of Representatives (ret.)

Government Consultant

Mike Pompeo

Of Counsel

Former U.S. Secretary of State

John W. Sellers

Former Senior DOJ Trial Attorney

Linda Julin McNamara

Federal Appeals Attorney

Nicholas B. Johnson

Former Prosecutor

Roger Bach

Former Special Agent (DOJ)

Chris J. Quick

Former Special Agent (FBI & IRS-CI)

Michael S. Koslow

Former Supervisory Special Agent (DOD-OIG)

Ray Yuen

Former Supervisory Special Agent (FBI)

What Is at Stake in a Dentaquest Pharmacy Audit?

Pharmacy benefit managers are a fact of life for most independent pharmacies. To conduct any business with an insurance company, a pharmacy must agree to work with a PBM. By making such an agreement, a pharmacy consents to an audit. If the audit goes poorly, Dentaquest has a variety of options. For example, if a Dentaquest audit reveals a pattern of billing errors, it can terminate the contract with the pharmacy. This would leave the pharmacy with no way to bill the insurance company for prescriptions.

However, there are also far less drastic yet still disruptive sanctions a PBM can impose. For example, if Dentaquest discovers errors that do not rise to the level of perceived misconduct justifying contract termination, it can seek a recoupment. Remember, a PBM is responsible for compensating pharmacies, and if a PBM determines that a pharmacy should not be compensated due to billing or other errors, it can withhold funds.

In some cases, a PBM audit gone wrong can also result in the PBM referring the alleged violation to state or federal regulators or law enforcement agencies.

What You Need to Know About a Dentaquest Pharmacy Audit

As a pharmacy owner, your focus is on efficiently running your business. While this necessarily entails possessing at least a cursory understanding of the regulatory environment in which pharmacies operate, most pharmacies do not have an advanced understanding of the PBM audit process. Below is a list of some important things you need to know about any PBM audit.

Saying “No” to a PBM Audit Comes at Great Cost

Under the terms of the contract you signed with Dentaquest, you agree to allow auditors to come into your pharmacy and review prescription and billing records. While technically refusing entry to auditors is theoretically possible, doing so will almost certainly result in the termination of a pharmacy’s contract with the PBM.

The Scope of an Audit is Not Unlimited

While Dentaquest auditors will not tell you this, their rights to conduct an audit are not without limits. Certainly, auditors can request to review certain documentation, and most auditors’ requests are within the bounds of their authority. However, requests that fall outside the scope of the PBM contract do not need to be honored. Of course, facing an unreasonable request by a PBM auditor put pharmacies in a challenging position. On one hand, unreasonable requests may be unduly burdensome and feel like the auditor is going on a fishing expedition for errors. On the other hand, appearing to be non-compliant may indicate to auditors that the pharmacy has something to hide. Thus, it is important to have an experienced PBM audit attorney present during the audit to explain to auditors exactly why their request cannot be honored under the terms of the contract.

Pharmacies Have Rights During the PBM Audit Process

Under general principles of contract law, a pharmacy subject to a PBM audit retains all rights outlined in a PBM contract. This includes the right to be free from requests made outside the contract, as well as additional rights. While the scope of a pharmacy’s rights will vary based on the specific contact as well as on the specific state laws at issue, they generally include at least the following:

The right to a clear explanation for any demand for recoupment;
The right to a limited and clearly defined look-back period;
The right to reasonable notice of the audit;
The right to receive timely notice of the results of the audit; and
The right to reimbursement for improperly denied claims.

Pharmacies Can Challenge Auditor’s Findings

The goal of a PBM audit is to make it through the process unscathed. However, PBM audits routinely end in a finding of one or more issues. In the event of an unfavorable audit, pharmacies are not without recourse. With the assistance of an experienced PBM audit lawyer, a pharmacy can either negotiate with the PBM to reduce or eliminate any sanction. In the event that Dentaquest is unwilling to engage in fair negotiations, a Dentaquest PBM audit lawyer can pursue legal action, for example, by seeking an injunction or other relief.

Frequently Asked Questions:

What should I look for in a Dentaquest pharmacy audit attorney?

The stakes in a Dentaquest pharmacy benefit manager audit are high. Yet, many lawyers shy away from representing pharmacies during PBM audits due to the complexity of the regulations and the overall lack of transparency in the process. Even healthcare defense lawyers who represent pharmacies in other compliance and regulation issues may not provide the level of comprehensive representation needed to successfully navigate a Dentaquest audit. If you face a Dentaquest audit, the most important thing to consider when selecting an attorney is their experience handling all aspects of a PBM audit. Ask any attorney you interview about their specific experience handling Dentaquest audits generally, as well as in the state where your pharmacy operates. You should also inquire about the results of past audits to get a better understanding of the lawyer’s ability to effectively guide you through the process. At Oberheiden, P.C., our Dentaquest PBM audit lawyers have extensive, hands-on experience representing pharmacies across the country in PBM audits, and are immediately available to discuss your situation.

Do I need to comply with all requests made by Dentaquest auditors?

While the PBM contract you signed with Dentaquest obligates you to cooperate with an audit on some level, you do not necessarily need to comply with all of an auditor’s requests. However, whether a request must be honored depends on the nature of the request and the specific language contained in the PBM contract. It is important to remember that Dentaquest has the right to terminate your contract, so exercising caution is imperative. The best approach is to allow a skilled PBM audit lawyer to handle all communications with the auditors, so they can provide auditors with legal and factual citations to all objections pertaining to a request for documentation.

Are certain prescriptions at greater risk of review in a Dentaquest audit?

While Dentaquest doesn’t officially state that prescriptions for any particular drug are subject to heightened scrutiny, initial prescription and refills for high-cost drugs appear to be at the center of most Dentaquest audits. Often, a PBM will initiate an audit to get their foot in door the, hoping to find a violation that will allow the company to withhold future funds that would otherwise be due to the pharmacy. When reviewing prescriptions, high-cost drugs offer Dentaquest the easiest way to recoup significant funds with the least amount of work. Thus, pharmacies subject to a Dentaquest audit should be prepared to provide all documentation related to any high-cost medications. An experienced PBM audit defense attorney at Oberheiden, P.C. can help pharmacies determine the propriety of any request for documentation.

Reach Out to the Dentaquest PBM Audit Lawyers at Oberheiden, P.C. Today

If Dentaquest recently announced a PBM audit of your pharmacy, the dedicated pharmacy audit defense lawyers at Oberheiden, P.C. are here to help you through every step of the process. Our senior attorneys are standing by, ready to immediately intervene in the audit to ensure your rights are protected and that the audit goes as favorably as possible. We can arrange to have a physical presence at the audit so our attorneys can keep an eye on auditors and communicate with them on your behalf. Our pharmacy defense lawyers also provide compliance consultation to independent pharmacies in advance of the Dentaquest audit, giving you advanced knowledge of any potential issues that may come up. We will also work with you to develop a strategic defense to overcome whatever issues are discovered. You can reach the firm by calling 888-680-1745 to schedule an appointment. You can also complete our online contact form, and one of our lawyers will reach out to you shortly.