Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Home Health Medicare Audits: Documentation Priorities
Homebound status, the face-to-face encounter, plan of care certification, and OASIS consistency drive the denials that recur in ho…
Medicaid Timely Filing and Retroactive Eligibility Issues
The 12-month Medicaid timely filing deadline and the 3-month retroactive eligibility window can collide and read to auditors as fr…
DME Medicare Audits: Proof of Delivery and Orders
How RAC and UPIC auditors reconstruct the DME documentation chain, from the standard written order to the proof of delivery on fil…
Medicaid Pharmacy Audits: State Program Integrity
How state Medicaid program integrity units audit pharmacy dispensing records, and how that process differs from a commercial PBM a…
Medicaid Enrollment Denials and Provider Screening
How the federal risk-level screening framework and ownership disclosure rules under 42 CFR Part 455 drive Medicaid enrollment deni…
Diagnostic Imaging Medicare Audits
Ordering physicians face signed-order documentation demands, a paused AUC penalty phase, and Stark Law self-referral exposure in i…
Managed Care SIU Investigations: What Providers Face
Managed care SIUs are plan-run fraud units, not government auditors, and can trigger prepayment holds, denials, and network termin…
Medicaid Credentialing and Re-Credentialing Denials
How Medicaid provider screening, risk-tier site visits, and exclusion database checks lead to credentialing denials, and how to ap…
Clinical Laboratory Medicare Audits
Medical necessity documentation, standing orders, and kickback exposure that shape how a clinical laboratory Medicare audit unfold…