Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Appealing a UPIC Overpayment Determination
UPIC overpayment determinations trigger Medicare's five-level appeal process, with strict 30- and 60-day windows controlling wheth…
UPIC Revocation Recommendations to CMS
How a UPIC finding becomes a CMS revocation recommendation, the regulatory ground it relies on, and where a physician's response c…
UPIC Versus SMRC: Two Different Reviews
SMRC review checks claims against coding rules. UPIC review investigates fraud, with site visits, payment suspension, and a law en…
UPIC Jurisdictions: Which Contractor Covers Your State
CMS assigns UPIC audits to five geographic jurisdictions, each with its own contractor. The current jurisdiction map, and why the…
UPIC Referrals to HHS-OIG and DOJ
A UPIC audit becomes a federal matter once HHS-OIG or DOJ receives a fraud referral. What triggers it, the timing, and how the pos…
UPIC Interview Requests: Should You Agree
A voluntary UPIC interview request is not a subpoena, but an unprepared answer can still shape a later civil or criminal fraud ref…
UPIC-Initiated Medicare Payment Suspensions
How a UPIC suspends Medicare payments on a credible allegation of fraud, the 15-day rebuttal window, and how long a suspension can…
UPIC Data Mining: How You Got Selected
How CMS's predictive analytics and peer-comparison scoring select physicians for a UPIC audit, and what a high-risk billing profil…
UPIC Beneficiary Interviews and What They Ask
When a UPIC contacts a physician's Medicare patients directly, what investigators ask and how those answers become part of the cas…