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 63
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GLP-1 Weight-Loss Claims Under PBM Review
PBM audit teams are reviewing brand GLP-1 claims for diagnosis mismatches, thin prior authorization records, and dosing patterns t…
Partial Fills and Audit Discrepancies
How Schedule II and III-V completion windows create billing mismatches that trigger PBM audit findings, and the documentation that…
Multi-Location Pharmacy Groups: Audit Exposure Across Stores
PBM audits opened against one store can extrapolate findings and expand network termination risk across every commonly owned pharm…
UPIC Audits of Behavioral Health Providers
UPICs are expanding fraud, waste, and abuse review of behavioral health billing, from CPT 90853 group therapy overuse to IOP and P…
Anti-Kickback Safe Harbors Every Practice Should Know
Medical director pay, space leases, EHR donations, and value-based deals must fit a safe harbor exactly, or the Anti-Kickback Stat…
Cellular and Tissue-Based Product Waste Billing
CMS ended wastage billing for skin substitutes effective January 1, 2026, and UPIC audits already test whether billed graft sizes…
Civil Discovery in FCA Cases: Managing the Burden
Once a qui tam case is unsealed, discovery reaches years of claims data. Rule 26 proportionality and privilege protocol decide who…
Appealing an OIG Exclusion
OIG exclusions carry a five-year mandatory minimum for program-related convictions, and the appeal runs through an ALJ hearing, no…
Physical Therapy Medicare Audits and the Therapy Threshold
CMS raised the 2026 KX modifier threshold to $2,480, but audit risk now turns on medical necessity, maintenance therapy, and note…