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 38
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When a Telehealth Audit Signals a Criminal Investigation
A Medicare telehealth audit can escalate into a federal criminal referral inside the same file. Here are the signals that mark the…
Indicted in a Healthcare Fraud Case: Arraignment and Release Conditions
What happens after a federal healthcare fraud indictment: self-surrender, arraignment, and Bail Reform Act release conditions, and…
Medicare Claim Reopenings Versus Appeals: Which Route Applies
Reopening and the Medicare appeals ladder are separate remedies, with different grounds, time limits, and effects on a provider's…
Legitimate Medical Purpose in Controlled Substance Prescribing
DEA reads a prescriber's own chart against 21 CFR 1306.04's legitimate medical purpose standard. What the record must show, and th…
NDC Mismatch Findings in a PBM Audit
PBM auditors treat a billed NDC that does not match the dispensed product as unverified, not underpriced, which is why the finding…
Medicaid Managed Care Network Termination: Appeal Routes
A Medicaid managed care plan can drop a provider by contract alone. Appeal routes, member notice duties, and state-level exclusion…
Getting Paid After a Favorable Medicare Appeal Decision
A Medicare appeal win does not guarantee prompt payment. Effectuation deadlines, interest rules, and CMS's referral power all shap…
Medicaid Audit Lookback Periods and the Sample Time Frame
Medicaid audit review periods are set state by state. A longer review period widens the base a sample is projected across.
Time-Based Telehealth Coding and Audit Findings
Program integrity contractors test telehealth time-based E/M coding for overlapping encounters and impossible-day patterns before…