Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Consumer-Directed Personal Care: Fiscal Intermediary and Employer Audits
Consumer-directed personal care splits control from paperwork, so the fiscal intermediary, the participant-employer, and the state…
Hospice Medical Director Responsibilities When an Audit Opens
When a hospice audit opens, the medical director's certification carries personal False Claims Act exposure separate from the hosp…
Oklahoma Health Care Authority Program Integrity Audits
An OHCA Program Integrity audit reviews SoonerCare claims for billing abuse, with fixed thirty-day windows to respond, reconsider,…
UPIC Audit Versus OIG Audit: Telling the Two Apart
A UPIC letterhead and an HHS-OIG letterhead carry different authority, different findings, and different appeal rights for the pro…
Coding, Clinical and Statistical Reviewers in a UPIC Rebuttal
How providers select independent coding, clinical and statistical reviewers, protect their reports, and build a persuasive UPIC re…
Kentucky Medicaid Program Integrity Audits and Appeals
Kentucky Medicaid audits run through two different tracks: the state's Division of Program Integrity and the managed care plans, e…
Hospice Change of Ownership and the 36-Month Rule
42 CFR 424.550 blocks a hospice's Medicare billing privileges from transferring when majority ownership changes within 36 months o…
Hospice Cap Overpayments: How the Aggregate Cap Is Calculated
42 CFR 418.309 sets a per-beneficiary dollar cap on Medicare hospice payments, and 42 CFR 418.302 caps inpatient days at 20 percen…
Formatting and Delivering a UPIC Records Production
A UPIC records production can fail on formatting alone: missing pages, unreadable copies, no index, and no proof of what was actua…