Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Medicaid Self-Audit Demand Letters: Options Before You Certify
A Medicaid self-audit letter can convert a routine compliance review into False Claims Act exposure. Scope the response before you…
Medicare Payment Suspensions: Credible Allegations and the Path Back
CMS can suspend Medicare payments on reliable information or a credible fraud allegation, long before any hearing on the underlyin…
UPIC Prepayment Review: The Exit Strategy
A UPIC holding claims for individual review freezes cash flow claim by claim. Here is the documented path CMS requires to end prep…
When a UPIC Audit Becomes a Law Enforcement Referral
A UPIC audit can escalate into a referral to HHS-OIG or DOJ. Here is what triggers it and why the audit response matters.
Medicaid Payment Suspensions Under 42 CFR 455.23
A credible allegation of fraud triggers a mandatory Medicaid payment suspension under 42 CFR 455.23, but a written rebuttal can li…
Medicare Prepayment Review: Getting Off the Payment Hold
A Medicare payment hold can drain a practice's cash reserves. Learn how providers land on prepayment review and the exit criteria…
SafeGuard Services UPIC Audits: What Providers Should Know
SafeGuard Services LLC is the CMS UPIC for the Northeast and Southeast. Here is how its fraud reviews unfold and what providers sh…
The Five Levels of Medicare Overpayment Appeals
A physician's guide to Medicare overpayment appeals: filing deadlines, recoupment timing, and where cases are won at each level.
Medicaid Managed Care Audits: How MCOs and PBMs Enforce Contract Terms
Medicaid MCOs delegate pharmacy audits to PBMs under 42 CFR Part 438, but the network contract, not state regulation, controls the…