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 28
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Healthcare Fraud Charges Against Pharmacists and Pharmacy Owners
How a PBM audit file and wholesaler records become a pharmacy fraud case, and who can be charged when a billing pattern draws a re…
Hospice Fraud Investigations: Eligibility and Certification Theories
How DOJ builds hospice fraud cases: certification theories, marketer and medical director payments, level-of-care billing, and the…
Medicaid Audit Triggers: How State Agencies Select Providers
How state Medicaid agencies flag providers for audit through peer billing comparisons, complaints, referrals, prior findings, and…
Medicare Audit Preparation Checklist for Physician Practices
A working checklist a physician practice can run before a Medicare audit notice ever arrives, and again on the day one does.
Medicare RAC Audits: Review Types, Record Requests, and Appeals
A Recovery Audit Contractor review, start to finish: automated versus complex review, record requests, the results letter, and whe…
Medicaid Audit Preparation Checklist for Provider Offices
A practical checklist for logging the notice, preserving records, reading the provider manual, and bringing in counsel before sign…
Medicaid Audit Consultants and Attorneys: Who Does What
Medicaid audit consultants and attorneys play different roles in an audit, and privilege over a consultant's work depends on how t…
Local Coverage Determinations: How MACs Use LCDs in an Audit
A Medicare audit denial citing a Local Coverage Determination turns on which policy version applied, how a MAC checked it claim by…
Hospice Billing Privilege Revocations and Payment Suspensions
CMS payment suspensions, billing-privilege revocations, heightened oversight of new hospices, and the current enrollment moratoriu…