Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Medicare Self-Audits: Scope, Privilege, and Handling the Findings
How a physician practice should scope a Medicare self-audit, why privilege is not automatic, and what the overpayment rule require…
Novitas Solutions Medicare Audits: TPE, Prepayment Review and Appeals
Novitas Solutions is the Medicare contractor for two jurisdictions. How its TPE reviews, documentation requests, and appeals actua…
Nursing Facility Medicaid Audits: MDS Reviews and Cost Reports
How state Medicaid agencies review nursing facility MDS assessments, cost reports and resident trust funds, and what follows a rec…
Medicaid Audit Triggers: How State Agencies Select Providers
How state Medicaid agencies flag providers for audit through peer billing comparisons, complaints, referrals, prior findings, and…
Medicare Audit Preparation Checklist for Physician Practices
A working checklist a physician practice can run before a Medicare audit notice ever arrives, and again on the day one does.
Medicare RAC Audits: Review Types, Record Requests, and Appeals
A Recovery Audit Contractor review, start to finish: automated versus complex review, record requests, the results letter, and whe…
Medicaid Audit Preparation Checklist for Provider Offices
A practical checklist for logging the notice, preserving records, reading the provider manual, and bringing in counsel before sign…
Medicaid Audit Consultants and Attorneys: Who Does What
Medicaid audit consultants and attorneys play different roles in an audit, and privilege over a consultant's work depends on how t…
Local Coverage Determinations: How MACs Use LCDs in an Audit
A Medicare audit denial citing a Local Coverage Determination turns on which policy version applied, how a MAC checked it claim by…