Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Medicaid Extrapolation Challenges at the State Level
State Medicaid extrapolation runs on state law, not the federal standard Medicare RAC and UPIC audits follow, and the sampling met…
Medical Necessity Denials: Building the Clinical Record
What Medicare auditors look for in the clinical record before denying a claim as not reasonable and necessary, and how physicians…
Medicaid Fair Hearings: Preparing Your Case
How a Medicaid provider should prepare evidence and witnesses before a fair hearing under 42 CFR Part 431, Subpart E.
Medicaid Dental Audits and Documentation
How Medicaid dental audits test radiograph support, medical necessity narratives for restorative work, and heightened pediatric cl…
Interest on Medicare Overpayments: How It Accrues
How interest accrues on a Medicare overpayment appeal under 42 CFR 405.378, how the rate is set, and what recoupment pauses do not…
Incident-To Billing: The Rules Auditors Apply
Medicare's incident-to billing rules require direct physician supervision and an established plan of care, and RAC and MAC auditor…
Medicaid Exclusion and Its Effect on Other Payers
How a state Medicaid exclusion reported to the OIG becomes a federal exclusion and a trigger for commercial payer network terminat…
Illinois Medicaid Audits and HFS-OIG Review
How the Illinois HFS Office of Inspector General audits Medicaid providers, recoups overpayments, withholds payments, and the appe…
Home and Community Based Services Audits
How CMS plan-of-care rules for 1915(c) and 1915(k) HCBS waivers work, what OIG audits have found, and the records providers need t…