Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
EPSDT Claims and Medicaid Audit Exposure
EPSDT is defined by five mandatory components, not one visit code. Incomplete documentation of any one of them is what state Medic…
Behavioral Health Medicare Audits
Medicare audits of behavioral health claims turn on session time and format documentation. What CMS and MAC guidance actually requ…
The Medicare ALJ Hearing: What to Expect
The Medicare ALJ hearing is the third level of appeals: qualifying thresholds, hearing format, witness testimony, the OMHA backlog…
Applied Behavior Analysis Medicaid Audits
OIG's multi-state ABA audit series found improper billing in nearly every sampled case. Supervision, session notes, and authorizat…
Texas Medicaid OIG Audits and Investigations
HHSC-OIG audits Texas Medicaid providers under Chapter 531, with payment holds and a SOAH appeal route that runs on strict, unforg…
Ambulance Medicare Audits: Medical Necessity and Destination
Repetitive non-emergent ambulance transport draws Medicare scrutiny on medical necessity, destination rules, and run-sheet documen…
Reinstatement After Medicaid Exclusion
Completing a Medicaid exclusion period does not restore eligibility. Covers OIG reinstatement timing, application standards, and s…
Personal Care Services Medicaid Audits
How state Medicaid auditors use EVV records, attendant timesheets, and aide qualification files to build personal care services ov…
Taking a Medicare Overpayment to Federal Court
Providers must exhaust five levels of Medicare appeal before federal court review, then face a strict deadline and a narrow standa…