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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UPIC Audits of Orthotics and Prosthetics Suppliers
UPIC audits of orthotics and prosthetics suppliers turn on custom fitting documentation, proof of delivery, and referral patterns…
Zone Program Integrity Contractors: The UPIC Predecessor
ZPICs investigated Medicare fraud from 2003 to 2016, when UPICs absorbed the role. Older ZPIC-era guidance still shapes how audits…
UPIC Audits of Pain Management Practices
UPIC audits of pain management practices examine injection frequency, urine drug testing billing, and controlled substance prescri…
Debridement Frequency and Medical Necessity Challenges
How Medicare frequency checkpoints and documentation standards determine whether a repeat debridement claim survives audit review.
COVID-Era Billing Under Retrospective Review
How the Section 1135 telehealth waivers that applied during the COVID-19 Public Health Emergency affect retrospective Medicare bil…
The 60-Day Rule in Practice for Medicare Providers
CMS replaced the reasonable diligence standard for the Medicare 60-day rule in 2025. What identification means now, and the FCA ex…
Defending a Declined Qui Tam Case
A declined qui tam case is not over. The relator can litigate alone under the False Claims Act, and the government retains real op…
Pharmacy Audit Defense: What Actually Reverses a Finding
PBM audit findings get reversed on three grounds: documentation the auditor rejected, ambiguous contract terms, and procedural def…
PBM Audits and Your Wholesaler Relationship
PBM invoice reconciliation audits can turn a pharmacy's wholesaler purchase records into a recoupment finding, even when shelf inv…