Insights & Analysis
Practical guidance on PBM audits, federal investigations, compounding defense, DEA enforcement, telehealth compliance, and the regulatory pressures facing pharmacies and providers nationwide.
More articles — Page 12
Page 12 of 70 · 635 articles
Usual and Customary Price Findings in PBM Audits
PBM auditors treat a pharmacy's usual and customary price as a real, enforceable number. Here is how the finding is calculated, tr…
Insurance Coverage for FCA Defense Costs
A civil investigative demand can trigger D&O coverage before a lawsuit is filed. What a policy actually pays for, and what it excl…
Product Purchase Records in Skin Substitute Audits
UPIC and MAC auditors now compare skin substitute purchase records against billed units. A shortfall between the two is becoming t…
Healthcare Fraud Takedowns: How Practices Get Swept In
The DOJ's coordinated healthcare fraud takedowns rely on data analytics that flag referring and ordering physicians alongside sche…
Independent Review Organizations: What They Actually Do
Independent review organizations audit claims under a Corporate Integrity Agreement, distinct from health plan appeal reviewers. W…
Individual Liability for Executives Under the FCA
The False Claims Act reaches individual executives, not just companies. What compliance officers need to know about personal expos…
UPIC Referrals to HHS-OIG and DOJ
A UPIC audit becomes a federal matter once HHS-OIG or DOJ receives a fraud referral. What triggers it, the timing, and how the pos…
Telehealth-Originated Prescriptions in PBM Audits
PBMs are increasingly recouping on prescriptions written through telehealth, citing invalid prescriber relationships. Here is how…
Pressure Ulcer Staging and Billing Accuracy
How pressure injury staging errors and present-on-admission coding gaps translate into HAC payment reductions and audit exposure f…