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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Health Care Fraud Strike Forces: How Cases Begin
How DOJ and HHS-OIG Health Care Fraud Strike Forces are structured, how data referrals and agencies combine, and the early signs a…
Fair Market Value and Commercial Reasonableness Under the Stark Law
Stark Law compensation arrangements must satisfy fair market value and commercial reasonableness as two separate, independently re…
Medicare Recoupment Across Related Providers and Shared Tax IDs
Medicare can recoup an overpayment from any provider that shares a tax ID with the audited one, putting whole medical groups and c…
Medicare Enrollment Site Visits: What the Inspector Checks
CMS inspectors can visit a Medicare-enrolled location unannounced. Here is what they verify, and how a failed visit becomes a revo…
Wound Care Modifiers Under Audit: 25, 59, JW and JZ
Medicare reviewers test modifiers 25, 59, JW and JZ on wound visits, debridement and skin substitute claims against the record, no…
Internal Compliance Complaints That Could Become Qui Tams
How a hotline or email complaint that goes undocumented and unresolved becomes the evidentiary backbone of a False Claims Act qui…
Inpatient Admission Status and the Two-Midnight Rule in FCA Cases
A short inpatient stay that misses Medicare's Two-Midnight Rule can become the fact pattern behind a False Claims Act qui tam case…
DOJ Voluntary Self-Disclosure Policy for Healthcare Companies
The DOJ Criminal Division Corporate Enforcement Policy sets six voluntary self-disclosure conditions and three tiers of credit tha…
Compliance Officer Liability in Healthcare Fraud Cases
Compliance officers can become named witnesses, relators, or certifying signatories in healthcare fraud cases over what they knew…