Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
New Jersey Medicaid Fraud Division Investigations
New Jersey Medicaid audits can trigger a parallel Medicaid Fraud Control Unit investigation, with separate civil and criminal expo…
New York OMIG Audits: Process and Defense
New York's OMIG moves audits through a draft report, a 30-day response window, and a 60-day appeal deadline that cannot be extende…
QIC Reconsideration: Building the Record for ALJ
Level 2 of the Medicare appeals process sets a 180-day filing deadline and an evidence rule that can decide the case before it rea…
Michigan Medicaid Audits and Provider Defense
How MDHHS OIG audits Michigan Medicaid providers, when self-audit and disclosure options apply, and how the state's appeal process…
Physician Orders and Certifications Under Audit
What a valid Medicare physician order or certification must contain, the timing and signature rules, and the defects that trigger…
Medicaid Transportation Provider Audits
State Medicaid programs and MFCUs are auditing non-emergency medical transportation providers over trip logs, eligibility, and mil…
Modifier 25 Audits: Separately Identifiable Service
How Medicare contractors evaluate modifier 25 claims, the documentation that supports separately identifiable E/M services, and co…
Medicaid Self-Disclosure: When and How
When a discovered Medicaid overpayment calls for self-disclosure, the federal 60-day rule, state variation, and how to preserve po…
Medicaid Provider Agreement Termination
For-cause termination, non-renewal, and the reinstatement route under 42 CFR 455.416 and 455.101, and why procedures vary by state…