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 6
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Willfulness Under the Anti-Kickback Statute After the ACA Amendment
The 2010 ACA amendment removed the need to prove specific intent to violate the Anti-Kickback Statute, but courts still require kn…
UPIC Audits of Office-Based Labs and Vascular Procedures
OIG found $105 million in office-based lab vascular payments may be medically unnecessary. What draws a UPIC audit, and what docum…
UPIC Audits of House Call and Home Visit Practices
What UPICs check first in a house call audit: place of service, homebound status, visit volume, and the records that answer the ma…
Relying on a Billing Company as a Defense to Criminal Fraud Charges
A billing company's errors do not excuse a provider once personal Medicare certifications establish what the provider knew and sig…
California Pharmacy Audit Rules and PBM Oversight
California law sets firm notice, lookback and appeal deadlines for PBM pharmacy audits, and routes new PBM licensure to DMHC, not…
Arkansas PBM Laws and Pharmacy Audit Protections
Arkansas regulates PBM audits through two statutes enforced by the Insurance Department, with limits set by ERISA and Medicare Par…
Global Surgery Package Audits: Modifiers 24, 57, 58, 78 and 79
Five CPT modifiers carve separately payable services out of Medicare's global surgery package. Reviewers check each against its ow…
First Coast Service Options Medicare Audits and Medical Review
First Coast Service Options runs Medicare medical review for Florida, Puerto Rico and the U.S. Virgin Islands, on a fixed 45-day A…
What a Pharmacist May Change on a Schedule II Prescription
DEA's own guidance leaves the line between a correction and a new prescription to state law, and a pharmacist who guesses wrong ca…