Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Treasury Referral of an Unpaid Medicare Overpayment
What happens once a Medicare overpayment demand goes unpaid: referral to Treasury for cross-servicing and offset, and what closes…
Medicaid Revalidation and Provider Number Deactivation
State Medicaid revalidation cycles trigger risk-based screening and site visits, and a missed window deactivates the provider numb…
Medicaid Recovery Audit Contractors and What They Review
A Medicaid RAC's contingency-fee review runs on a different track than a state program integrity audit or a managed care plan's SI…
Medicaid Prepayment Review and Documentation Requirements
Medicaid prepayment review holds each claim for documentation before payment. A payment suspension freezes all claims at once, and…
Overlapping Contractor Reviews: UPIC, MAC, and RAC at the Same Time
CMS requires Medicare review contractors to coordinate overlapping UPIC, MAC, and RAC reviews of the same claims, but a provider s…
Medicare Claim Reopenings Versus Appeals: Which Route Applies
Reopening and the Medicare appeals ladder are separate remedies, with different grounds, time limits, and effects on a provider's…
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.