Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Corrective Action Plans After Medicare Revocation
A Medicare revocation opens a 30-day window for a Corrective Action Plan and a 60-day window for reconsideration, and missing eith…
California Medi-Cal Audits and Recovery
How DHCS selects providers for a Medi-Cal audit, how the overpayment and withhold work, and the OAHA appeal sequence providers mus…
Behavioral Health Medicaid Audits
State Medicaid audits of behavioral health providers turn on service definitions, staff credentialing files, and time-based billin…
CMS-855 Enrollment Errors That Trigger Revocation
CMS revokes Medicare billing privileges over CMS-855 misrepresentation, missed 30-day ownership reports, and undisclosed felony co…
Change of Ownership and Medicare Enrollment Risk
A Medicare change of ownership can transfer the seller's overpayment liability to the buyer. What CHOW mechanics and CMS-855 timin…
SMRC Audits: What Providers Should Know
The Supplemental Medical Review Contractor runs CMS-directed project reviews with a 45 day ADR deadline. Here is how compliance of…
Medicaid Self-Audit Demand Letters: Options Before You Certify
A Medicaid self-audit letter can convert a routine compliance review into False Claims Act exposure. Scope the response before you…
Medicare Payment Suspensions: Credible Allegations and the Path Back
CMS can suspend Medicare payments on reliable information or a credible fraud allegation, long before any hearing on the underlyin…
UPIC Prepayment Review: The Exit Strategy
A UPIC holding claims for individual review freezes cash flow claim by claim. Here is the documented path CMS requires to end prep…