Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Home Health Homebound Status: Proving It Under Review
The two-part CMS test for homebound status, the absences that do not break it, and the documentation that actually survives a Medi…
The Medicare Program Integrity Manual: Chapters That Govern an Audit
CMS writes this manual for its Medicare contractors, distinct from a statute. The chapters a provider under audit needs, and how t…
Recoupment in Medical Billing: What It Means and How Medicare Collects
Medicare recoupment withholds an overpayment from future payments, not just the audited claims. Here is how it works and how it di…
DME Supplier Compliance Programs: Referrals, Marketing and Screening
OIG's DME compliance guidance covers referral and marketing arrangements, exclusion screening, refill rules, and accreditation, no…
Commercial Insurer Audits of Medical Practices: Contracts and Recoupment
Commercial insurer audits run on the provider agreement and plan type, not Medicare rules. What providers should know before respo…
UPIC Medicaid Audits and the Medi-Medi Program
UPICs audit Medicaid claims too. How the Medi-Medi data match, the state's overpayment process, and MFCU referrals actually work.
State Medicaid Exclusion Lists: Screening Beyond the Federal LEIE
Several states publish their own Medicaid exclusion or sanction list separate from the federal LEIE, and screening only one can mi…
TPE Versus UPIC Review: Telling Education From Investigation
A Targeted Probe and Educate letter corrects billing error. A UPIC audit investigates fraud, and either can lead to the other.
UPIC Audits of Podiatry Practices: Routine Foot Care and Nail Care
How UPIC and MAC reviewers test podiatry claims for routine foot care and nail debridement, and what charts need to show.