Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Clinical Laboratory Requisitions and Medical Necessity Under Review
CMS requires the ordering physician, not the lab, to document medical necessity, and the lab carries the payment risk if that reco…
PDGM Coding and Audit Exposure for Home Health Agencies
How PDGM's principal diagnosis, OASIS functional scoring, and comorbidity adjustment set home health payment, and where Medicare a…
UPIC Audits of Dermatology Practices: Mohs, Biopsies and Destruction Codes
UPICs flag dermatology practices by Mohs staging ratios, biopsy volume and destruction coding. Here is the documentation that supp…
UPIC Audits of Anesthesia Services
A UPIC auditing anesthesia claims tests billed time and medical direction attestations against the facility's own anesthesia and O…
OASIS Accuracy and Its Role in Home Health Payment Disputes
OASIS functional scores that outpace the clinician's own visit notes can turn routine home health claims into Medicare overpayment…
Hospice Visit Frequency and Plan of Care Gaps in Audits
How Medicare auditors compare the hospice plan of care under 42 CFR 418.56 to actual visits, IDG reviews, and missed-visit documen…
Federally Qualified Health Center Medicaid Audits and Payment Rates
How the Medicaid prospective payment system sets FQHC rates, how wrap-around payments work, and where encounter-claim audits creat…
Hospice Provisional Period of Enhanced Oversight
CMS places newly enrolled and changed-ownership hospices in six states under 100% prepayment review before claims are paid.
Hospice Patients in Assisted Living: Why the Claims Get Extra Scrutiny
OIG data show hospice stays in assisted living run far longer than other settings, and the certification record is what a reviewer…