Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Medicaid Pharmacy Audits: State Program Integrity
How state Medicaid program integrity units audit pharmacy dispensing records, and how that process differs from a commercial PBM a…
Medicaid Enrollment Denials and Provider Screening
How the federal risk-level screening framework and ownership disclosure rules under 42 CFR Part 455 drive Medicaid enrollment deni…
Diagnostic Imaging Medicare Audits
Ordering physicians face signed-order documentation demands, a paused AUC penalty phase, and Stark Law self-referral exposure in i…
Managed Care SIU Investigations: What Providers Face
Managed care SIUs are plan-run fraud units, not government auditors, and can trigger prepayment holds, denials, and network termin…
Medicaid Credentialing and Re-Credentialing Denials
How Medicaid provider screening, risk-tier site visits, and exclusion database checks lead to credentialing denials, and how to ap…
Clinical Laboratory Medicare Audits
Medical necessity documentation, standing orders, and kickback exposure that shape how a clinical laboratory Medicare audit unfold…
Chronic Care Management Billing Under Audit
CCM claims fail audits over vague time logs, missing consent, and generic care plans. What CMS requires, and what a review looks f…
Duplicate Billing Findings in Medicaid Audits
Duplicate claims are among the most common Medicaid audit findings. Whether one resolves as a refund or a fraud referral turns on…
Chiropractic Medicare Audits: The AT Modifier Problem
Medicare requires the AT modifier to prove active chiropractic treatment, not maintenance care. What the documentation has to show…