Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
Compromise and Settlement of a UPIC Overpayment
CMS can compromise a Medicare overpayment of $100,000 or less, but any indication of fraud removes that option and sends the claim…
Complaints and Tips That Start a UPIC Investigation
Complaints, tips and referrals from beneficiaries, employees, competitors and the OIG Hotline can open a UPIC investigation as fas…
Medicaid Substance Use Disorder Treatment Provider Audits
Medicaid audits of outpatient, IOP, residential and OTP providers turn on ASAM level-of-care proof, drug-testing patterns and grou…
Medicaid Psychotherapy Time Coding and Audit Findings
Medicaid reviewers downcode or deny psychotherapy claims that lack face-to-face time documentation, and the exposure can extrapola…
DME Supplier Standards and Revocation for Noncompliance
DME suppliers can lose Medicare billing privileges for failed site visits, insurance lapses, or hours violations, not just claims…
DME Standard Written Order Requirements
A missing element on a DME order under 42 CFR 410.38 denies the claim outright and can extrapolate into a large recoupment demand.
Disputing a Managed Care Plan Recoupment Notice
A Medicaid MCO recoupment notice starts a dispute under the plan's contract. State review, like New Jersey's PICPA process, follow…
DentaQuest and MCNA Audits of Medicaid Dental Providers
How DentaQuest and MCNA Dental select Medicaid dental claims for audit, the documentation they expect, and the deadlines to appeal…
DME Prior Authorization: The Required List and How It Works
CMS requires prior authorization before paying certain DME claims. Here is the current required list, provisional affirmation, and…