Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
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…
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…