Provider Defense | BOLO Health Law, LLC
Facing a PBM Audit, SIU Investigation, or Payer Recoupment?
A commercial payer or PBM dispute may involve a contract amendment, an SIU finding, a recoupment calculation or a threat to network participation. Those are distinct issues, and Medicare appeal assumptions do not necessarily apply. BOLO helps selected healthcare providers and pharmacies assess payer agreements, claims records and contract-specific response rights with attention to what the dispute means for revenue and continued operations.
Start with the audit notice, the relevant payer or PBM, the amount at issue, and any response or appeal deadline.
First steps: preserve the notice and the evidence
The notice itself governs the immediate task. Before making a substantive response, identify the issuing authority, the precise request and any applicable deadline.
- Keep the complete notice, envelopes, attachments and delivery information together.
- Preserve the existing clinical, billing, business and electronic records without altering or backdating them.
- Identify the requested records, dates of service, personnel and claims. Track how any production is assembled and transmitted.
- Escalate urgent dates promptly. Do not assume an inquiry to the firm extends a government, payer or court deadline.
Important: These are general preservation principles, not instructions to withhold records, disregard a lawful demand or miss a deadline. The proper response depends on the actual notice.
How Representation Can Be Structured
Payer and PBM disputes can involve successive audit responses, contract review, and appeals. BOLO discusses the likely scope and billing method based on the notice and record. Learn how BOLO engagements work.
Related legal services: Pharmacy & PBM Audit Defense · Payer Underpayment Recovery · RCM & Vendor Contracts · All Practice Areas
Where we represent providers
Three Common Areas of Payer Defense
SIU Investigations & Audits
- SIU investigations
- Audits
- Record requests
- Medical necessity issues
- Coding disputes
PBM, Recoupment & Payment
- Recoupments
- Repayment demands
- Payment holds
- Claim denials
- Underpayments
- Unpaid claims
Network, Termination & Credentialing
- Network termination
- Credentialing disputes
Time matters
Identify the Contract, Scope & Response Deadline.
Payer and PBM disputes can move quickly. The governing contract, records requested, audit methodology, and applicable response deadlines should be assessed before a substantive reply.
A practical response
Put a strategy in place before you act
01
Review the Notice
Identify the payer or PBM, the contract and notice at issue, the specific demand, and any appeal or response deadline.
02
Preserve & Review Records
Preserve relevant records and review the production request promptly with counsel while meeting any applicable legal or contractual obligation.
03
Know your deadlines
Identify every response date in the payer’s notices so none is missed.
04
Move forward with a plan
Prepare an accurate response grounded in documentation, the applicable contract or policy, and available review or appeal rights.
Choose the correct route for a payer dispute
Network termination, claim underpayment and an SIU recoupment demand should not be treated as interchangeable payer actions. The agreement, notice, relevant claim records and deadline determine which response is available.
Get started
Contact BOLO Health Law and get a strategy in place.
If your organization faces a PBM audit, SIU inquiry, recoupment, denial, or network action, contact BOLO promptly with the relevant notice and deadline.
Prefer to speak with the firm? Call 609-200-6677. Please do not share confidential information before conflicts are checked.
Payer dispute pathways: choose the correct contract and remedy
Commercial network disputes, PBM recoupments, SIU requests and Medicare claims operate under different legal rules. The contract, notice and benefit arrangement determine the first step.
- Commercial payer underpayments: find the contract-based claim
- SIU interview requests: preserve records and control the response
- PBM network termination and contractual appeal rights
- Pharmacy and PBM defense services
Prepare for review: preserve the executed agreement, amendments, current manuals, notices, claim and payment data, proof of receipt and every deadline. Request counsel so the actual dispute pathway is assessed before escalation.
See BOLO’s research standards for source hierarchy, authorship and limitations. Information is not case-specific advice; only a written engagement establishes representation.