Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Hospice Billing Privilege Revocations and Payment Suspensions
CMS payment suspensions, billing-privilege revocations, heightened oversight of new hospices, and the current enrollment moratoriu…
Appealing a Medicare Revocation: Reconsideration and DAB Review
A Medicare revocation appeal runs through reconsideration, an ALJ hearing at the DAB, and further review, with billing stopped thr…
CMS and the UPIC: Which Contractor Actions Need CMS Approval
A UPIC requests records and makes review findings itself. Payment suspension and revocation need CMS approval first, per CMS's own…
UPIC Requests for EHR Access, Audit Trails, and Metadata
When a UPIC asks for EHR access, an audit trail, or chart metadata, scope and production choices shape what the reviewer finds and…
UPIC Reopenings: How Far Back Paid Claims Can Be Reviewed
A UPIC reopening of a paid claim runs on the 42 C.F.R. 405.980 standard, not a fixed lookback number, and it is not the sample per…
UPIC Records Requests Versus OIG Subpoenas: What Compels Production
A UPIC records request and an HHS-OIG subpoena rest on different legal authority and carry different consequences for non-producti…
UPIC Medical Review: Nurse Reviewers and Contractor Medical Directors
How a UPIC medical necessity denial moves from coding staff to a nurse reviewer to a contractor medical director, and what a rebut…
Medicare Waiver of Recovery and Limitation on Liability
Waiver of recovery and limitation on liability can each eliminate a Medicare overpayment demand, but they turn on different proof…
UPIC Audit Results Letters: Reading the Findings and Responding
A UPIC review results letter states claim-by-claim findings, the error rate, and any extrapolated overpayment before the file reac…