Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
CoventBridge UPIC Audits: Process and Response
CoventBridge holds CMS's Midwest UPIC contract. Here is how its Medicare and Medicaid fraud reviews unfold, and how physicians sho…
Challenging Extrapolation in Medicare Overpayment Demands
A small claims sample can produce a six-figure Medicare demand. Learn how the sampling universe and methodology can be challenged.
Medicaid Fair Hearings: Appealing Audit and Enrollment Actions
How the Medicaid fair hearing process works under 42 CFR Part 431: notice, evidentiary record, and preserving payment during appea…
Medicare Billing Privilege Revocations Under 42 CFR 424.535
A physician's guide to Medicare revocation grounds, the reenrollment bar, corrective action plan deadlines, and the appeal path un…
UPIC Site Visits: How to Prepare and What Inspectors Review
An unannounced UPIC site visit can arrive without warning. What inspectors review, how staff interviews work, and why counsel belo…
The Credible Allegation of Fraud Standard in Medicaid Enforcement
A thin, unverified referral can trigger a mandatory Medicaid payment suspension. Here is how states define a credible fraud allega…
UPIC Audits Explained: The Fraud-Focused Medicare Contractor
UPICs investigate suspected Medicare and Medicaid fraud, not payment accuracy. What a UPIC letter means and how its mandate differ…
Medicaid Exclusion and Termination: Collateral Consequences of an Audit
A state Medicaid termination for cause can trigger mandatory cross-state termination and federal OIG exclusion. What physicians sh…
When to Engage a Medicare Audit Attorney
The points in a Medicare audit where legal exposure escalates: extrapolated demands, prepayment review, fraud referrals, and revoc…