Healthcare

Pharmacy

Ankura offers a cross functional team includes former prosecutors, clinicians as well as financial, reimbursement, and compliance experts who employ the skill sets, experience, and passion necessary to support our clients facing litigation, government enforcement, and compliance challenges related to the payment, delivery, and supply of prescription drugs. Our team of experts have collaborated with our clients to leverage their diverse experience to successfully resolve some of the most challenging disputes, enforcement, and compliance issues in the industry.

Ankura’s experts assist counsel across the entire spectrum of pharmacy benefits, including retail, hospital, and specialty pharmacies; distributors; pharmacy benefit managers; and plan sponsors. Our expertise includes: the quantification of financial exposure through analytic and statistical methods; prescription drug claims submission and payment; pharmacy benefit administration; Medicare Part D compliance; and the preparation of expert and consultative reports shared with prosecutors or used in commercial litigation. We’ve assisted our clients on many False Claim Act, Anti-Kickback Statute, Controlled Substance Act and commercial litigation matters that involved the analysis of billions of pharmacy claims transactions to defend against allegations involving:

  • Usual and customary pricing and discount programs.
  • Prescription drug billing errors and overpayments.
  • Improper payment and administration of prescription drug benefits.
  • Copay waivers, gift card programs, and copay cards.
  • Medically unnecessary medications, improper prior authorization, and
    formulary administration.
  • Improper financial arrangements with referral sources.
  • Drug diversion and other criminal activities.
  • Suspicious order monitoring
  • 340B dispensing and billing compliance.

Our services include:

  • Disputes and Forensics Solutions for Pharmacy

    Ankura quickly and efficiently helps clients analyze, understand, and resolve complex disputes and issues encountered in the defense and prevention of government investigations, qui tam actions, or compliance initiatives.

    We understand the complex environment in which pharmacy companies operate and the related dispute, investigation, and litigation support issues they face. Our team of experts includes pharmacists, data analysts, statisticians, economists, industry management, and payor/PBM experts who work with clients to address their most high-risk areas of disputes and compliance including:

    • False Claims Act/qui tam defense
    • Kickbacks and fraudulent inducement
    • Improper billing to government programs
    • Contract disputes
    • CMS sanctions

    Our team has extensive experience in analyzing these claims and providing testimony, either in a litigation setting through presentations to government investigators. We have a track record of credibility with the government assisting our clients in the successful resolution of investigations.

  • Risk, Regulatory, and Compliance Solutions for Pharmacy

    We help clients navigate the complex regulatory and compliance environment in which they operate, addressing their most high-risk areas of operations and compliance including, diversion, Usual and customary pricing; manufacturer coupon use; promotional gift cards; billing and payment accuracy; narrowing networks; and oversight of downstream entities. Ankura supports client’s needs across all government programs — Medicare, Medicaid, SCHIP, DOD/TRICARE, VA and IHS as well as the continuum of payers and providers in the pharmacy space.

    Our services include:

    • Forensic data analytics
    • Ongoing auditing and monitoring
    • System/software reviews
    • Operational compliance
    • Mock audits/transactional audits
    • Corrective action plan projects/IVA (e.g. Medicare Part D)
    • Risk assessment
    • Monitoring/IRO
    • Due diligence
    • Valuation services
  • Data Analytic Capabilities

    Ankura combines deep industry and regulatory experience with data analytics and clinical and billing expertise to provide clients with best in class service and sustainable solutions. Our depth of experience across the pharmacy supply chain and analyzing billions of pharmacy, wholesaler, PBM, and payor transactions allows us to quickly learn our client’s systems and operations, which corresponds to quickly and efficiently providing synthesized and actionable analysis.

    Our experience includes:

    • Developing analytical data repositories linking all relevant transactional data (often disparate)
    • Performing forensic data analyses to determine irregularities and the corresponding risk and financial exposure
    • Developing sampling methodologies to test the accuracy of claims billing
    • Selecting probe samples to determine potential error rates
    • Developing statistically valid sampling methodologies (using OIG approved methodology) to quantify potential error rates
    • Preparing exhibits documenting our findings for use in counsel’s presentations to the government
    • Repricing large volumes of claims to review contract compliance, payment accuracy, and exposure related to improper billing.
    • Analyzing suspicious order monitoring programs
    • Evaluating data for red flags of diversion
Get in Touch
Jed Smith
Jed Smith
Managing Director
Mary Beth Edwards
Mary Beth Edwards
Senior Managing Director