Insights & Analysis
Practical guidance on PBM audits, federal investigations, compounding defense, DEA enforcement, telehealth compliance, and the regulatory pressures facing pharmacies and providers nationwide.
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Materiality as a Defense: Government Knowledge
Escobar made FCA materiality a demanding standard. Continued government payment despite knowledge of a violation is very strong ev…
Laboratory Kickback Enforcement: Process and Handling Fees
Specimen processing fees look like overhead reimbursement, but the OIG's 2014 alert and $48.5M in DOJ settlements show how they be…
Individual Accountability in Corporate Healthcare Cases
DOJ's March 2026 Department-wide Corporate Enforcement Policy keeps individual prosecution the priority in corporate healthcare fr…
When to Involve Counsel in a PBM Audit
The audit notice does not announce its own stakes. Which PBM audit decisions actually turn on counsel, and which ones turn on the…
UPIC Revocation Recommendations to CMS
How a UPIC finding becomes a CMS revocation recommendation, the regulatory ground it relies on, and where a physician's response c…
What a PBM Audit Costs an Independent Pharmacy
Recoupment is only one line item. Staff hours, a mid-audit cash-flow offset, and a missed appeal deadline each add their own cost…
UPIC Versus SMRC: Two Different Reviews
SMRC review checks claims against coding rules. UPIC review investigates fraud, with site visits, payment suspension, and a law en…
UPIC Jurisdictions: Which Contractor Covers Your State
CMS assigns UPIC audits to five geographic jurisdictions, each with its own contractor. The current jurisdiction map, and why the…
Selecting a Skin Substitute: Documenting Medical Necessity
How to document product selection, conservative care, and wound measurement so a skin substitute claim holds up under Medicare's 2…