Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Reinstatement After Medicaid Exclusion
Completing a Medicaid exclusion period does not restore eligibility. Covers OIG reinstatement timing, application standards, and s…
Personal Care Services Medicaid Audits
How state Medicaid auditors use EVV records, attendant timesheets, and aide qualification files to build personal care services ov…
Taking a Medicare Overpayment to Federal Court
Providers must exhaust five levels of Medicare appeal before federal court review, then face a strict deadline and a narrow standa…
Signature Requirements in Medicare Documentation
How CMS defines a valid Medicare signature, when a signature log or attestation statement can fix a missing or illegible one, and…
RAC Audits Versus UPIC Audits: Know Which One You Have
RAC audits chase improper payments for a contingency fee. UPIC audits investigate fraud and can trigger a payment suspension befor…
New Jersey Medicaid Fraud Division Investigations
New Jersey Medicaid audits can trigger a parallel Medicaid Fraud Control Unit investigation, with separate civil and criminal expo…
New York OMIG Audits: Process and Defense
New York's OMIG moves audits through a draft report, a 30-day response window, and a 60-day appeal deadline that cannot be extende…
QIC Reconsideration: Building the Record for ALJ
Level 2 of the Medicare appeals process sets a 180-day filing deadline and an evidence rule that can decide the case before it rea…
Michigan Medicaid Audits and Provider Defense
How MDHHS OIG audits Michigan Medicaid providers, when self-audit and disclosure options apply, and how the state's appeal process…