Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
E/M Level Selection Under Audit After the 2021 Changes
Since 2021, physicians choose an E/M level by time or medical decision making. Medicare audits test whether the note supports whic…
Florida AHCA Medicaid Audits: Overpayment Calculation and Hearing Rights
AHCA calculates Florida Medicaid overpayments through statistical extrapolation and gives providers 21 days to request a Chapter 1…
Electronic Visit Verification and Medicaid Audit Findings
Medicaid EVV records verify home visits, and mismatches are now central evidence in personal care and home health audit findings.
Corrective Action Plans After Medicare Revocation
A Medicare revocation opens a 30-day window for a Corrective Action Plan and a 60-day window for reconsideration, and missing eith…
California Medi-Cal Audits and Recovery
How DHCS selects providers for a Medi-Cal audit, how the overpayment and withhold work, and the OAHA appeal sequence providers mus…
Behavioral Health Medicaid Audits
State Medicaid audits of behavioral health providers turn on service definitions, staff credentialing files, and time-based billin…
CMS-855 Enrollment Errors That Trigger Revocation
CMS revokes Medicare billing privileges over CMS-855 misrepresentation, missed 30-day ownership reports, and undisclosed felony co…
Change of Ownership and Medicare Enrollment Risk
A Medicare change of ownership can transfer the seller's overpayment liability to the buyer. What CHOW mechanics and CMS-855 timin…
SMRC Audits: What Providers Should Know
The Supplemental Medical Review Contractor runs CMS-directed project reviews with a 45 day ADR deadline. Here is how compliance of…