Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Responding to a Medicare Additional Documentation Request (ADR)
Medicare ADR deadlines run 45 days for MAC, RAC, and SMRC requests, 30 days for UPIC requests. What a complete response package mu…
Qlarant UPIC Audits: Jurisdiction and Process
Qlarant runs UPIC fraud investigations across the Western and Southwestern jurisdictions. What triggers a review, what the samplin…
Responding to a UPIC Records Request
A UPIC records request starts a 30-day clock, demands a complete production, and requires a privilege review most practices skip u…
State Medicaid OMIG Audits: Process and Defense
How New York's OMIG audit process works: records demands, the six-year lookback, extrapolation, and the 60-day window to appeal a…
CERT Audits and Error Rate Findings: The Provider Response
How the CERT program samples Medicare claims, calculates the error rate, and what a provider must do after an improper payment fin…
Medicaid Fraud Control Unit Investigations: What Providers Face
A Medicaid Fraud Control Unit investigation can proceed on a civil track, a criminal track, or both. Here is what providers need t…
The Medicare Audit Process: Contractors, Stages, and Deadlines
MAC, RAC, UPIC, SMRC, CERT: which Medicare contractor is auditing you determines the risk. The stages and deadlines every provider…
CMS Imposes Nationwide Moratorium on Hospice and Home Health Enrollments: A Major Escalation in the J.D. Vance Task Force Crackdown
The Centers for Medicare & Medicaid Services (CMS) has imposed a six-month nationwide moratorium on new hospice and home health pr…
The 2025 Healthcare Fraud Takedown Is a Warning Shot for Wound Care Providers
Wound care is now an enforcement priority. The 2025 fraud takedown targets skin substitute billing, graft utilization, and Medicar…