Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
UPIC Audits of Partial Hospitalization and Intensive Outpatient Programs
UPIC reviews of PHP and IOP claims turn on physician certification timing, program hours, and individualized progress notes.
Medicare Advantage Plan Special Investigations Units and Provider Audits
A Medicare Advantage plan's own Special Investigations Unit, not a federal contractor, opens provider audits under Part C.
Medicare Advantage Chart Review Programs and Add-Only Diagnoses
How Medicare Advantage plans add diagnoses through retrospective chart review, and why add-only practices draw False Claims Act sc…
UPIC Audits of Office-Based Labs and Vascular Procedures
OIG found $105 million in office-based lab vascular payments may be medically unnecessary. What draws a UPIC audit, and what docum…
UPIC Audits of House Call and Home Visit Practices
What UPICs check first in a house call audit: place of service, homebound status, visit volume, and the records that answer the ma…
Global Surgery Package Audits: Modifiers 24, 57, 58, 78 and 79
Five CPT modifiers carve separately payable services out of Medicare's global surgery package. Reviewers check each against its ow…
First Coast Service Options Medicare Audits and Medical Review
First Coast Service Options runs Medicare medical review for Florida, Puerto Rico and the U.S. Virgin Islands, on a fixed 45-day A…
Self-Disclosure and Voluntary Refunds While a UPIC Audit Is Open
What an open UPIC review does to the Medicare overpayment reporting clock, which channel fits, and the risk of an uncoordinated re…
Privilege and Confidentiality in a UPIC Production
What physician practices can withhold or log when producing records to a UPIC, and how privilege survives later disclosure.