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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Genetic Testing Fraud Schemes: How Prosecutors Build Them
How prosecutors build genetic testing fraud cases around telemarketing, physician orders, and lab billing, and what it means for r…
When a Managed Care SIU Refers Your Case to the State
Federal rules require Medicaid managed care plans to refer suspected fraud to the state agency or the MFCU. Here is what triggers…
Settling a Medicaid Overpayment Before the Final Audit Report
A state Medicaid overpayment can be negotiated before the final report issues, but the settlement must address referral and exclus…
Return to Stock and Unclaimed Prescriptions in PBM Audits
A paid claim never picked up is a classic PBM audit finding. The reversal timing and will-call records a pharmacy keeps decide whe…
Reading an OptumRx Network Termination Notice
An OptumRx network termination notice states a reason, a cited provision, and an effective date. Here is how to read each part and…
Deactivation Versus Revocation of Medicare Billing Privileges
Medicare deactivation pauses billing and leaves a path back in. Revocation ends the provider agreement and can bar reenrollment fo…
Continuous Home Care in Hospice: Medical Review Triggers
Continuous home care is hospice's most expensive level of care. Here is the hour count, staffing mix, and crisis proof Medicare re…
Wasting Controlled Substances: Witness and Documentation Standards
What a controlled substance waste record must contain, who has to witness it, and how DEA investigators test it for diversion.
Testosterone Prescribing and DEA Scrutiny of Men's Health Clinics
Testosterone is Schedule III. DEA scrutiny of men's health clinics turns on registration, telehealth limits, records, and legitima…