Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Hospice Special Focus Program: What Being Selected Means
CMS paused the Hospice Special Focus Program in February 2025. Here is how the selection algorithm works and what placement would…
Social Adult Day Care Prepayment Review and Payment Suspension
New York has ordered health plans to apply prepayment review to social adult day care claims. Here is how that differs from a paym…
Adult Day Care Medicaid Audits
New York has ordered prepayment review of social adult day care claims. Here is what 9 NYCRR 6654.20 requires on file before a Med…
Hospice Six-Month Prognosis: What Auditors Need to See in the Record
Medicare reviewers test the six-month hospice prognosis against clinical decline markers, not the diagnosis code on the claim.
Hospice Face-to-Face Encounters for Recertification
A hospice recertification is incomplete without a timely, properly attested face-to-face encounter, and a missed one denies the wh…
Hospice Election Statements: The Errors That Void a Benefit Period
The elements a hospice election statement needs, the addendum CMS made mandatory October 1, 2026, and the filing errors that put a…
New Jersey Medicaid Audits by the Office of the State Comptroller
How the NJ Office of the State Comptroller's Medicaid Fraud Division audits providers, from document requests through the appeal d…
Medicaid Audits of Nursing Homes: Level of Care and Eligibility
State Medicaid auditors test whether nursing facility residents meet PASRR and level-of-care eligibility, not just billing documen…
Home Health Review Choice Demonstration: Choosing Your Option
CMS's Review Choice Demonstration runs pre or postpayment review on home health claims in six states, with a 90% target to earn re…