Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Medicare Prepayment Review: Getting Off the Payment Hold
A Medicare payment hold can drain a practice's cash reserves. Learn how providers land on prepayment review and the exit criteria…
SafeGuard Services UPIC Audits: What Providers Should Know
SafeGuard Services LLC is the CMS UPIC for the Northeast and Southeast. Here is how its fraud reviews unfold and what providers sh…
The Five Levels of Medicare Overpayment Appeals
A physician's guide to Medicare overpayment appeals: filing deadlines, recoupment timing, and where cases are won at each level.
Medicaid Managed Care Audits: How MCOs and PBMs Enforce Contract Terms
Medicaid MCOs delegate pharmacy audits to PBMs under 42 CFR Part 438, but the network contract, not state regulation, controls the…
CoventBridge UPIC Audits: Process and Response
CoventBridge holds CMS's Midwest UPIC contract. Here is how its Medicare and Medicaid fraud reviews unfold, and how physicians sho…
Challenging Extrapolation in Medicare Overpayment Demands
A small claims sample can produce a six-figure Medicare demand. Learn how the sampling universe and methodology can be challenged.
Medicaid Fair Hearings: Appealing Audit and Enrollment Actions
How the Medicaid fair hearing process works under 42 CFR Part 431: notice, evidentiary record, and preserving payment during appea…
Medicare Billing Privilege Revocations Under 42 CFR 424.535
A physician's guide to Medicare revocation grounds, the reenrollment bar, corrective action plan deadlines, and the appeal path un…
UPIC Site Visits: How to Prepare and What Inspectors Review
An unannounced UPIC site visit can arrive without warning. What inspectors review, how staff interviews work, and why counsel belo…