Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Medicaid Fair Hearings: Preparing Your Case
How a Medicaid provider should prepare evidence and witnesses before a fair hearing under 42 CFR Part 431, Subpart E.
Medicaid Dental Audits and Documentation
How Medicaid dental audits test radiograph support, medical necessity narratives for restorative work, and heightened pediatric cl…
Interest on Medicare Overpayments: How It Accrues
How interest accrues on a Medicare overpayment appeal under 42 CFR 405.378, how the rate is set, and what recoupment pauses do not…
Incident-To Billing: The Rules Auditors Apply
Medicare's incident-to billing rules require direct physician supervision and an established plan of care, and RAC and MAC auditor…
Medicaid Exclusion and Its Effect on Other Payers
How a state Medicaid exclusion reported to the OIG becomes a federal exclusion and a trigger for commercial payer network terminat…
Illinois Medicaid Audits and HFS-OIG Review
How the Illinois HFS Office of Inspector General audits Medicaid providers, recoups overpayments, withholds payments, and the appe…
Home and Community Based Services Audits
How CMS plan-of-care rules for 1915(c) and 1915(k) HCBS waivers work, what OIG audits have found, and the records providers need t…
Immediate Recoupment: Should You Request It
How Medicare overpayment interest under 42 CFR 405.378 weighs against a physician's appeal rights, and when requesting immediate r…
Failing Round Three of TPE: What Happens Next
What happens when a physician's error rate stays high after three rounds of TPE: MAC referral to CMS, prepayment review, extrapola…