Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
UPIC Audits of Urgent Care Centers
Urgent care centers face UPIC scrutiny over E/M leveling errors and facility fee codes Medicare will not pay. What draws the revie…
UPIC Audits of Toxicology and Drug Testing Labs
UPIC audits of toxicology labs turn on definitive versus presumptive testing, custom panels, and whether the ordering physician do…
UPIC Audits of Orthotics and Prosthetics Suppliers
UPIC audits of orthotics and prosthetics suppliers turn on custom fitting documentation, proof of delivery, and referral patterns…
Zone Program Integrity Contractors: The UPIC Predecessor
ZPICs investigated Medicare fraud from 2003 to 2016, when UPICs absorbed the role. Older ZPIC-era guidance still shapes how audits…
UPIC Audits of Pain Management Practices
UPIC audits of pain management practices examine injection frequency, urine drug testing billing, and controlled substance prescri…
The 60-Day Rule in Practice for Medicare Providers
CMS replaced the reasonable diligence standard for the Medicare 60-day rule in 2025. What identification means now, and the FCA ex…
Statistical Sampling in Medicare Audits: Where It Breaks
CMS lets auditors extrapolate a small claims sample into a full repayment demand. Here is where the sample frame and unit definiti…
Skilled Nursing Facility Audits Under PDPM
PDPM tied SNF payment to MDS coding accuracy, and OIG and CMS built new audit programs around exactly that vulnerability.
UPIC Audits of Hospice Providers
UPIC audits target long-stay hospice patients and thin physician narratives. Here is what 42 CFR 418.22 requires and how to defend…