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 18
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UPIC Audits of Remote Patient Monitoring Practices
How UPICs select RPM claims for review, what an additional documentation request covers, extrapolation risk, and the appeal path a…
RPM in Assisted Living and Senior Living Facilities
Assisted living and senior living residents live in a non-skilled setting with different billing, consent and enrollment rules for…
RPM Audits Targeting Nursing Facility Patients
When RPM claims cluster on nursing facility residents, contractors check the 16-day data threshold, duplicate monitoring by facili…
Remote Patient Monitoring Fraud Enforcement
OIG found $536 million in 2024 Medicare RPM payments and five billing patterns tied to fraud, followed by an RPM-specific False Cl…
Negotiating a PBM Audit Settlement
A PBM audit settlement should resolve the recoupment, the payment plan and the pharmacy's network status as separate, written term…
Live Discharges From Hospice and the Audit Questions They Raise
CMS data show the hospice live discharge rate rising, and auditors test whether the chart shows a patient's revocation or the hosp…
Hospice Special Focus Program: What Being Selected Means
CMS paused the Hospice Special Focus Program in February 2025. Here is how the selection algorithm works and what placement would…
Social Adult Day Care Prepayment Review and Payment Suspension
New York has ordered health plans to apply prepayment review to social adult day care claims. Here is how that differs from a paym…
Adult Day Care Medicaid Audits
New York has ordered prepayment review of social adult day care claims. Here is what 9 NYCRR 6654.20 requires on file before a Med…