Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Medicare Billing Privilege Revocations Under 42 CFR 424.535
A physician's guide to Medicare revocation grounds, the reenrollment bar, corrective action plan deadlines, and the appeal path un…
UPIC Site Visits: How to Prepare and What Inspectors Review
An unannounced UPIC site visit can arrive without warning. What inspectors review, how staff interviews work, and why counsel belo…
The Credible Allegation of Fraud Standard in Medicaid Enforcement
A thin, unverified referral can trigger a mandatory Medicaid payment suspension. Here is how states define a credible fraud allega…
UPIC Audits Explained: The Fraud-Focused Medicare Contractor
UPICs investigate suspected Medicare and Medicaid fraud, not payment accuracy. What a UPIC letter means and how its mandate differ…
Medicaid Exclusion and Termination: Collateral Consequences of an Audit
A state Medicaid termination for cause can trigger mandatory cross-state termination and federal OIG exclusion. What physicians sh…
When to Engage a Medicare Audit Attorney
The points in a Medicare audit where legal exposure escalates: extrapolated demands, prepayment review, fraud referrals, and revoc…
Responding to a Medicare Additional Documentation Request (ADR)
Medicare ADR deadlines run 45 days for MAC, RAC, and SMRC requests, 30 days for UPIC requests. What a complete response package mu…
Qlarant UPIC Audits: Jurisdiction and Process
Qlarant runs UPIC fraud investigations across the Western and Southwestern jurisdictions. What triggers a review, what the samplin…
Responding to a UPIC Records Request
A UPIC records request starts a 30-day clock, demands a complete production, and requires a privilege review most practices skip u…