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 65
Page 65 of 114 · 1029 articles
Unannounced UPIC Site Visits: Handling the Knock
What authority UPIC investigators have to enter your practice, what to hand over on the spot, and how to control an unannounced si…
Modifier 59 and Unbundling Allegations
How Medicare's NCCI edits govern modifier 59, when an unbundling pattern becomes an audit finding, and how it can turn into a Fals…
How to Write a PBM Audit Response Letter
How pharmacies structure a point-by-point rebuttal, organize exhibits, and avoid admissions that undermine a later PBM audit appea…
Part D Prescriber Enrollment and Preclusion
How CMS's Part D preclusion list works: who gets added, how it cuts off prescribing payment nationwide, and how to challenge inclu…
Responding to a UPIC Additional Documentation Request
A UPIC Additional Documentation Request starts a 30-day clock. How to build an indexed, complete production before a late response…
Peer Comparison Outliers and Audit Selection
CMS flags physicians for UPIC review by comparing their billing to a peer group. Why an outlier ranking is a screening signal, not…
Controlled Substance Claims in a PBM Audit
When a PBM audit flags controlled substance claims, the same dispensing patterns can trigger DEA scrutiny. Sequencing the response…
Discount Card Claims and PBM Audit Scrutiny
Discount card claims like GoodRx route through the PBM, and a mismatched usual and customary price can trigger a full-lookback PBM…
Third Party Liability and Medicaid as Payer of Last Resort
How Medicaid's payer of last resort rule works: cost avoidance, pay and chase, the narrow exceptions, and the recoupment exposure…