Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Home Health Agency Referral Arrangements and Kickback Risk
Home health payments to marketers, physicians and referral sources can trigger Anti-Kickback Statute liability. What the safe harb…
UPIC Audits of Physical Therapy Practices
UPIC audits of physical therapy claims turn on the KX modifier threshold, timed-code units, plan of care certification, and CPT 97…
UPIC Audits of Mental Health Counselors and Marriage and Family Therapists
MFTs and MHCs are Medicare's newest independently billing provider type. UPICs test the credential, the supervision record, and th…
UPIC Audits of Infusion and Injection Drug Claims
A UPIC infusion-drug audit checks whether the JW or JZ modifier matches the purchase invoice and the administration record, not ju…
General Inpatient Hospice Care Under Medical Review
GIP is hospice's second-highest-paying level of care, and Medicare reviews it closely. The record must justify it day by day, not…
Two-Midnight Rule Inpatient Denials: A Hospital Response Guide
A two-midnight denial from a Medicare Administrative Contractor is not final. Hospitals can rebill under Part B or appeal, each on…
UPIC Audits of Evaluation and Management Visits in Facilities
UPIC audits of nursing facility E/M visits turn on visit frequency under 42 CFR 483.30, medical necessity, and copied progress not…
Teaching Physician Rules and Resident Documentation Audits
Medicare pays for resident-provided visits only when a teaching physician's presence is documented; a resident's note describing t…
Timed Therapy Codes and the Eight-Minute Rule Under Audit
Medicare converts timed therapy minutes into 15-minute units under a fixed chart. Auditors find overpayments where billed units ou…