Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
UPIC Audits of Ambulance Suppliers
Repetitive non-emergent transport claims draw UPIC scrutiny over run sheet documentation, physician certification statements, and…
Unannounced UPIC Site Visits: Handling the Knock
What authority UPIC investigators have to enter your practice, what to hand over on the spot, and how to control an unannounced si…
Modifier 59 and Unbundling Allegations
How Medicare's NCCI edits govern modifier 59, when an unbundling pattern becomes an audit finding, and how it can turn into a Fals…
Part D Prescriber Enrollment and Preclusion
How CMS's Part D preclusion list works: who gets added, how it cuts off prescribing payment nationwide, and how to challenge inclu…
Responding to a UPIC Additional Documentation Request
A UPIC Additional Documentation Request starts a 30-day clock. How to build an indexed, complete production before a late response…
Peer Comparison Outliers and Audit Selection
CMS flags physicians for UPIC review by comparing their billing to a peer group. Why an outlier ranking is a screening signal, not…
Third Party Liability and Medicaid as Payer of Last Resort
How Medicaid's payer of last resort rule works: cost avoidance, pay and chase, the narrow exceptions, and the recoupment exposure…
Medicare Telehealth Audits After the Flexibilities Expired
Medicare telehealth flexibilities lapsed twice in five months before Congress extended them through 2027. What changed, what staye…
When a Medicaid Audit Becomes a Criminal Investigation
The concrete signals that a civil Medicaid audit has become a criminal referral, from a payment suspension to an MFCU interview re…