Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Medicaid Managed Care Plan Audits Versus State Audits
How a managed care plan's SIU review differs from a state Medicaid program integrity audit, and why a provider can face both on th…
Medicare Redetermination: Winning at Level One
What a Medicare redetermination request must include, the 120-day filing deadline, and why treating Level One as a formality costs…
MAC Targeted Probe and Educate: What TPE Really Means
What triggers a Medicare Administrative Contractor's Targeted Probe and Educate review, the three-round structure, and the referra…
Medicaid Extrapolation Challenges at the State Level
State Medicaid extrapolation runs on state law, not the federal standard Medicare RAC and UPIC audits follow, and the sampling met…
Medical Necessity Denials: Building the Clinical Record
What Medicare auditors look for in the clinical record before denying a claim as not reasonable and necessary, and how physicians…
Medicaid Fair Hearings: Preparing Your Case
How a Medicaid provider should prepare evidence and witnesses before a fair hearing under 42 CFR Part 431, Subpart E.
Medicaid Dental Audits and Documentation
How Medicaid dental audits test radiograph support, medical necessity narratives for restorative work, and heightened pediatric cl…
Interest on Medicare Overpayments: How It Accrues
How interest accrues on a Medicare overpayment appeal under 42 CFR 405.378, how the rate is set, and what recoupment pauses do not…
Incident-To Billing: The Rules Auditors Apply
Medicare's incident-to billing rules require direct physician supervision and an established plan of care, and RAC and MAC auditor…