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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Timely Filing Denials on Wound Care Claims
A wound care claim that misses Medicare's 12-month filing deadline, even one delayed by prepayment review, can be denied with no r…
WISeR Prior Authorization Denied for a Skin Substitute: Next Steps
A non-affirmed WISeR request is not a denial. What to fix on resubmission, when to request peer review, and when the standard appe…
Commercial Insurer Audits of Medical Practices: Contracts and Recoupment
Commercial insurer audits run on the provider agreement and plan type, not Medicare rules. What providers should know before respo…
Who Files Qui Tam Suits Against Healthcare Providers
Qui tam suits against healthcare providers come from billers, compliance officers, departing staff, competitors, and data-mining f…
Whistleblower Suits Against Telehealth Companies
A telehealth company typically first learns of a qui tam case against it from a civil investigative demand, months before any comp…
Texas Medical Board Complaints: Process and Response
A Texas Medical Board complaint moves through jurisdictional screening, investigation, an informal conference, and a contested cas…
Surgical Dressing Claims: Supplier Records Under DME MAC Review
Home dressings bill to the DME MAC on a track separate from the clinic's procedure claims, and that track draws its own contractor…
State Attorney General Investigations of Telehealth Companies
State attorneys general use consumer protection law, not payer rules, to probe telehealth advertising, billing, clinician oversigh…
Med Spa Medical Directors and Board Complaints
A board complaint against a med spa medical director turns on supervision and ownership, not whether the physician treated a patie…