Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
SNF Three-Day Qualifying Stay Errors and Denials
A two-day inpatient hospital stay does not qualify for Medicare SNF coverage. Here is how the three-day count, current waivers, an…
L3 Denials and Medicare Payment Suspensions
Seeing L3 "denials" on a Medicare remittance? The L3 code can signal a payment suspension. What it means, how suspensions work, an…
Missouri MMAC Medicaid Audits and Provider Defense
MMAC reviews MO HealthNet provider billing, can extrapolate an overpayment from a sample, and gives a provider 30 days to appeal t…
UPIC Audits of Wound Care in Nursing Facilities
A $45M DOJ settlement with a bedside wound care provider shows how UPIC audits reach nursing facility records, not just the billin…
SNF Consolidated Billing: Which Services Belong on the Facility Claim
Medicare's SNF consolidated billing rule bundles nearly every service into the facility's claim, and outside suppliers that bill P…
Skilled Nursing Facility Medical Review: The Skilled Need Question
Medicare's skilled-need test, not patient improvement, decides whether a Part A stay survives medical review under the Jimmo maint…
UPIC Audits of Skilled Nursing Facilities
UPICs review SNF consolidated billing and PDPM coding, and a small sample of flagged claims can be extrapolated into a demand many…
UPIC Audits of Remote Patient Monitoring Practices
How UPICs select RPM claims for review, what an additional documentation request covers, extrapolation risk, and the appeal path a…
Live Discharges From Hospice and the Audit Questions They Raise
CMS data show the hospice live discharge rate rising, and auditors test whether the chart shows a patient's revocation or the hosp…