Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Immediate Recoupment: Should You Request It
How Medicare overpayment interest under 42 CFR 405.378 weighs against a physician's appeal rights, and when requesting immediate r…
Failing Round Three of TPE: What Happens Next
What happens when a physician's error rate stays high after three rounds of TPE: MAC referral to CMS, prepayment review, extrapola…
Good Cause Exceptions to a Medicaid Payment Suspension
42 CFR 455.23(e) lets a state decline a Medicaid fraud payment suspension when beneficiary access to care is at risk, if the provi…
Georgia Medicaid Audits and Program Integrity Review
How DCH's Program Integrity Unit audits Georgia Medicaid providers, the records it demands, and the 10-day OSAH appeal deadline.
Face-to-Face Encounter Requirements and Audit Denials
How 42 CFR 424.22 and 42 CFR 410.38 define the Medicare face-to-face encounter, what the note must show, and why audits deny it.
Extended Repayment Schedules for Medicare Overpayments
ERS eligibility under 42 CFR 401.607, the hardship and extreme hardship showings, and structuring repayment around practice cash f…
E/M Level Selection Under Audit After the 2021 Changes
Since 2021, physicians choose an E/M level by time or medical decision making. Medicare audits test whether the note supports whic…
Florida AHCA Medicaid Audits: Overpayment Calculation and Hearing Rights
AHCA calculates Florida Medicaid overpayments through statistical extrapolation and gives providers 21 days to request a Chapter 1…
Electronic Visit Verification and Medicaid Audit Findings
Medicaid EVV records verify home visits, and mismatches are now central evidence in personal care and home health audit findings.