Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Medicaid Managed Care Network Termination: Appeal Routes
A Medicaid managed care plan can drop a provider by contract alone. Appeal routes, member notice duties, and state-level exclusion…
Getting Paid After a Favorable Medicare Appeal Decision
A Medicare appeal win does not guarantee prompt payment. Effectuation deadlines, interest rules, and CMS's referral power all shap…
Medicaid Audit Lookback Periods and the Sample Time Frame
Medicaid audit review periods are set state by state. A longer review period widens the base a sample is projected across.
Filing a Medicare Rebuttal Statement Before Recoupment Begins
What a Medicare rebuttal statement can and cannot do before recoupment begins, its filing window, and why it is not a substitute f…
Escalating a Medicare Appeal After a Missed Decision Deadline
What happens when a QIC or ALJ misses its own Medicare appeal deadline, how a provider requests escalation, and what escalating ac…
Corrective Action Plans After a Medicaid Audit
What a state Medicaid agency expects in a corrective action plan after an audit finding, who signs it, the follow-up review, and t…
Change of Ownership in Medicaid: Disclosure and Successor Liability
Buying or selling a Medicaid-enrolled provider means updating ownership disclosures, checking the seller's open audits and overpay…
Cloned Documentation and Copy-Forward Findings in Medicare Audits
How Medicare reviewers identify cloned or copy-forward EHR notes, why the finding becomes a medical necessity denial, and how to c…
AdvanceMed UPIC Audits: What to Expect
AdvanceMed's Midwestern Jurisdiction UPIC work now runs under the name CoventBridge. What the rebrand means for a physician facing…