Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Filing a Medicare Rebuttal Statement Before Recoupment Begins
What a Medicare rebuttal statement can and cannot do before recoupment begins, its filing window, and why it is not a substitute f…
Escalating a Medicare Appeal After a Missed Decision Deadline
What happens when a QIC or ALJ misses its own Medicare appeal deadline, how a provider requests escalation, and what escalating ac…
Corrective Action Plans After a Medicaid Audit
What a state Medicaid agency expects in a corrective action plan after an audit finding, who signs it, the follow-up review, and t…
Change of Ownership in Medicaid: Disclosure and Successor Liability
Buying or selling a Medicaid-enrolled provider means updating ownership disclosures, checking the seller's open audits and overpay…
Cloned Documentation and Copy-Forward Findings in Medicare Audits
How Medicare reviewers identify cloned or copy-forward EHR notes, why the finding becomes a medical necessity denial, and how to c…
AdvanceMed UPIC Audits: What to Expect
AdvanceMed's Midwestern Jurisdiction UPIC work now runs under the name CoventBridge. What the rebrand means for a physician facing…
Medicare Advantage Plan Audits Versus Traditional Medicare
Medicare Advantage plans audit under provider contracts and RADV rules, not Medicare regulations, which changes both the audit tri…
Ownership Disclosure Requirements in Medicaid Enrollment
Medicaid providers must disclose 5 percent owners and managing employees, and nursing facilities must now name private equity and…
Hospice Medicare Audits and Eligibility Challenges
CMS and OIG are scrutinizing hospice terminal prognosis documentation, long lengths of stay, and the aggregate cap under 42 CFR 41…