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 17
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Pharmacy Audit Defense: What Actually Reverses a Finding
PBM audit findings get reversed on three grounds: documentation the auditor rejected, ambiguous contract terms, and procedural def…
PBM Audits and Your Wholesaler Relationship
PBM invoice reconciliation audits can turn a pharmacy's wholesaler purchase records into a recoupment finding, even when shelf inv…
Compliance Program Effectiveness as a Defense
How DOJ's charging factors and the Sentencing Guidelines' three-point culpability reduction reward a compliance program that actua…
Statistical Sampling in Medicare Audits: Where It Breaks
CMS lets auditors extrapolate a small claims sample into a full repayment demand. Here is where the sample frame and unit definiti…
CTP Reimbursement Changes and What They Mean for 2027
CMS moved skin substitute reimbursement to a flat per-square-centimeter rate in 2026. A proposed 2027 rule would extend it to non-…
Debridement Depth Coding: 11042 Through 11047
CPT 11042-11047 pay on the deepest tissue removed, not the deepest visible. What documentation each depth tier needs, and how gaps…
Skilled Nursing Facility Audits Under PDPM
PDPM tied SNF payment to MDS coding accuracy, and OIG and CMS built new audit programs around exactly that vulnerability.
Copay Assistance Programs and Federal Enforcement
OIG's independence rules for charity copay foundations, and the settlements, including Teva's $450 million resolution, that define…
UPIC Audits of Hospice Providers
UPIC audits target long-stay hospice patients and thin physician narratives. Here is what 42 CFR 418.22 requires and how to defend…