Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
UPIC Audits When a Third-Party Billing Company Prepared the Claims
The provider stays the party of record when a UPIC audits claims a third-party biller prepared. What to gather, what contract term…
Responding to a Draft Medicaid Audit Report
A draft Medicaid audit report sets the record the rest of the case works from. Letting the response window pass turns findings int…
The RAC Discussion Period: Raising Issues Before the Demand Letter
The 30-day RAC discussion period runs on the review results letter, not the demand letter, and it does not pause the separate 120-…
Treasury Referral of an Unpaid Medicare Overpayment
What happens once a Medicare overpayment demand goes unpaid: referral to Treasury for cross-servicing and offset, and what closes…
Medicaid Revalidation and Provider Number Deactivation
State Medicaid revalidation cycles trigger risk-based screening and site visits, and a missed window deactivates the provider numb…
Medicaid Recovery Audit Contractors and What They Review
A Medicaid RAC's contingency-fee review runs on a different track than a state program integrity audit or a managed care plan's SI…
Medicaid Prepayment Review and Documentation Requirements
Medicaid prepayment review holds each claim for documentation before payment. A payment suspension freezes all claims at once, and…
Overlapping Contractor Reviews: UPIC, MAC, and RAC at the Same Time
CMS requires Medicare review contractors to coordinate overlapping UPIC, MAC, and RAC reviews of the same claims, but a provider s…
Medicare Claim Reopenings Versus Appeals: Which Route Applies
Reopening and the Medicare appeals ladder are separate remedies, with different grounds, time limits, and effects on a provider's…