Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Medicare Overpayment Demand Letters: Reading Yours Correctly
How to read a Medicare overpayment demand letter correctly: the required contents, the extrapolation sample behind the number, and…
Getting Off UPIC Prepayment Review
There is no published error-rate threshold that ends UPIC prepayment review. What actually determines exit, and how practices mana…
Challenging Extrapolation in a UPIC Audit
How CMS's extrapolation rules work, where UPIC sampling methodology breaks down, and the deadline that decides whether providers c…
School-Based Medicaid Services Under Audit
How school districts get audited on Medicaid-billed IEP services, and the documentation and provider-qualification gaps that drive…
Medicare Advantage RADV Audits: Risk Adjustment Exposure
How CMS validates Medicare Advantage HCC diagnoses through RADV chart review, where extrapolation stands after litigation, and whe…
Medicare Audit Defense for Small Practices
A proportionate response to a Medicare overpayment demand protects a small practice's cash flow and appeal rights inside the first…
Preparing for a Medicaid Site Visit
How announced and unannounced Medicaid site visits work, what inspectors check, and how to prepare staff and records in advance.
Medicaid Recoupment and Your Cash Flow
How Medicaid payment suspension under 42 CFR 455.23 and prospective recoupment withholds affect cash flow, and how to negotiate re…
HCC Coding Accuracy and Risk Adjustment Enforcement
Unsupported HCC diagnosis codes inflate Medicare Advantage risk scores and can expose physician groups to RADV audits and False Cl…