Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Physician Orders and Certifications Under Audit
What a valid Medicare physician order or certification must contain, the timing and signature rules, and the defects that trigger…
Medicaid Transportation Provider Audits
State Medicaid programs and MFCUs are auditing non-emergency medical transportation providers over trip logs, eligibility, and mil…
Modifier 25 Audits: Separately Identifiable Service
How Medicare contractors evaluate modifier 25 claims, the documentation that supports separately identifiable E/M services, and co…
Medicaid Self-Disclosure: When and How
When a discovered Medicaid overpayment calls for self-disclosure, the federal 60-day rule, state variation, and how to preserve po…
Medicaid Provider Agreement Termination
For-cause termination, non-renewal, and the reinstatement route under 42 CFR 455.416 and 455.101, and why procedures vary by state…
Medicare Revalidation: Getting It Right the First Time
The five-year cycle under 42 CFR 424.515, why a missed deadline triggers deactivation rather than revocation, and how to reactivat…
Medicare Reenrollment Bars: How Long You Are Out
The bar under 42 CFR 424.535(c) runs one to 10 years, longer for felony convictions or a second revocation, and it follows a physi…
Medicare Appeals Council Review After an ALJ Loss
The 60-day deadline, the Council's de novo standard, and when escalating a Medicare ALJ loss toward federal court is worth pursuin…
Medicaid Payment Suspension: Getting the Hold Lifted
How the credible allegation of fraud standard triggers a Medicaid payment suspension under 42 CFR 455.23, and the good-cause argum…