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 15
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Preserving Your Appeal Rights in a PBM Audit
Waiver traps hide in the correspondence that comes before the formal appeal. What preserves a pharmacy's PBM audit appeal rights,…
Hyperbaric Oxygen Therapy Audits
CMS covers hyperbaric oxygen therapy for only fifteen conditions, and OIG audits found the majority of sampled claims failed to do…
False Claims Act Exposure in Managed Care
Medicare Advantage risk-adjustment settlements now reach chart-review vendors and provider groups, not just the plan that submits…
Clinical, Coding, and Statistical Witnesses in FCA Litigation
Clinical, coding, and statistical witness testimony, not the paper record alone, typically decides whether an FCA claim is false a…
Data Analytics in Federal Healthcare Fraud Cases
How DOJ and CMS use predictive analytics and claims data to target physicians for fraud investigations, and how a statistics-first…
UPIC Audits of Urgent Care Centers
Urgent care centers face UPIC scrutiny over E/M leveling errors and facility fee codes Medicare will not pay. What draws the revie…
Pharmacy Audit Documentation Retention Requirements
Medicare Part D, PBM contracts, and state pharmacy boards each set a different retention clock, and purging early can cost a pharm…
Diabetic Foot Ulcer Documentation Requirements
Medicare's Local Coverage Determinations specify exact documentation for diabetic foot ulcer care: Wagner grading, vascular assess…
Deferred and Non-Prosecution Agreements in Healthcare
When DOJ offers a healthcare company a deferred or non-prosecution agreement instead of an indictment, and the obligations that co…