Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Preparing Staff for a UPIC Audit Without Coaching Them
Preparing staff for a UPIC audit means explaining the process, not scripting answers, and that line determines obstruction exposur…
Medicaid Hospice Audits and Dual-Eligible Residents
Medicaid, not Medicare, pays room and board for dual-eligible nursing facility residents on hospice, and state auditors watch that…
Standing Orders and Reflex Testing Under Medicare Review
Medicare treats a reflex test as part of the original order, but a standing order never proves medical necessity for an individual…
Split/Shared Visit Billing Under Medicare Audit
Medicare pays only the practitioner who performs the substantive portion of a split or shared visit, and a documentation gap can d…
Medicaid Durable Medical Equipment Audits
Medicaid DME audits turn on prior authorization, the prescribing order, and proof of delivery, and the exact rules vary by state.
Massachusetts MassHealth Audits and Provider Defense
A MassHealth overpayment notice starts a 30-day clock. Here is how the audit, the notice, and the Board of Hearings appeal actuall…
Skilled Nursing Need in Home Health: Observation, Teaching and Management
Medicare tests home health skilled nursing need three separate ways: observation and assessment, teaching and training, and care p…
SNF Minimum Data Set Accuracy and Payment Audits
The MDS assessment sets a SNF stay's PDPM payment group, and Medicare reviewers recompute that classification against the resident…
Revocation for Failing to Furnish Documentation on Request
Medicare can revoke billing privileges under 42 CFR 424.535(a)(10) when a provider fails to furnish documentation required by 424.…