Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Revocation for a Pattern or Practice of Noncompliant Billing
CMS can revoke Medicare billing privileges for a pattern of noncompliant claims, not just one bad claim. Here is what 42 CFR 424.5…
Assisted Living Medicaid Waiver Audits
Assisted living providers face Medicaid HCBS waiver audits testing the federal settings rule, the service plan, and recoupment acr…
Arizona AHCCCS Audits and Provider Appeals
AHCCCS OIG audits can lead to payment suspension or termination. Here is how the Arizona provider appeal process works, step by st…
Reading Medicare CARC and RARC Codes in Audit Denials
A Medicare remittance advice denial carries CARC and RARC codes that determine whether a claim needs a correction or a formal appe…
PAMA Clinical Laboratory Fee Schedule Reporting and Audit Risk
PAMA requires many clinical laboratories to report private payor rates to CMS, and reporting errors carry civil penalties and audi…
Palmetto GBA Medicare Audits: What Providers in Its Jurisdictions Face
Palmetto GBA runs Medicare medical review, Targeted Probe and Educate, and documentation-request deadlines across Jurisdiction M a…
Noridian Healthcare Solutions Medicare Audits and Appeals
Noridian's Medicare jurisdictions, its Targeted Probe and Educate process, and how its redetermination unit handles appeals and de…
Medicare Recoupment Across Related Providers and Shared Tax IDs
Medicare can recoup an overpayment from any provider that shares a tax ID with the audited one, putting whole medical groups and c…
Medicare Enrollment Site Visits: What the Inspector Checks
CMS inspectors can visit a Medicare-enrolled location unannounced. Here is what they verify, and how a failed visit becomes a revo…