Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
State Medicaid OMIG Audits: Process and Defense
How New York's OMIG audit process works: records demands, the six-year lookback, extrapolation, and the 60-day window to appeal a…
CERT Audits and Error Rate Findings: The Provider Response
How the CERT program samples Medicare claims, calculates the error rate, and what a provider must do after an improper payment fin…
Medicaid Fraud Control Unit Investigations: What Providers Face
A Medicaid Fraud Control Unit investigation can proceed on a civil track, a criminal track, or both. Here is what providers need t…
The Medicare Audit Process: Contractors, Stages, and Deadlines
MAC, RAC, UPIC, SMRC, CERT: which Medicare contractor is auditing you determines the risk. The stages and deadlines every provider…
CMS Imposes Nationwide Moratorium on Hospice and Home Health Enrollments: A Major Escalation in the J.D. Vance Task Force Crackdown
The Centers for Medicare & Medicaid Services (CMS) has imposed a six-month nationwide moratorium on new hospice and home health pr…
The 2025 Healthcare Fraud Takedown Is a Warning Shot for Wound Care Providers
Wound care is now an enforcement priority. The 2025 fraud takedown targets skin substitute billing, graft utilization, and Medicar…
SafeGuard Audits: Don't Let CMS's Contractor Infringe Your Rights
Providers need to know their rights when it comes to investigations and audits by CMS UPIC contractors, such as SafeGuard and Qlar…
Introduction to Medicare Audits
The federal government (HHS-OIG) is prioritizing audits of pharmacy claims in 2024. This signals that increased enforcement action…