Insights & Analysis
Practical guidance on PBM audits, federal investigations, compounding defense, DEA enforcement, telehealth compliance, and the regulatory pressures facing pharmacies and providers nationwide.
Master Formulation Records and Compounding Records Under Inspection
What a master formulation record and a compounding record must contain, who has to sign off, and the documentation gaps inspectors cite.
All articles
Page 1 of 86 · 774 articles
Hospice Fraud Investigations: Eligibility and Certification Theories
How DOJ builds hospice fraud cases: certification theories, marketer and medical director payments, level-of-care billing, and the…
Medicaid Audit Triggers: How State Agencies Select Providers
How state Medicaid agencies flag providers for audit through peer billing comparisons, complaints, referrals, prior findings, and…
Medicare Audit Preparation Checklist for Physician Practices
A working checklist a physician practice can run before a Medicare audit notice ever arrives, and again on the day one does.
Medicare RAC Audits: Review Types, Record Requests, and Appeals
A Recovery Audit Contractor review, start to finish: automated versus complex review, record requests, the results letter, and whe…
Medicaid Audit Preparation Checklist for Provider Offices
A practical checklist for logging the notice, preserving records, reading the provider manual, and bringing in counsel before sign…
Medicaid Audit Consultants and Attorneys: Who Does What
Medicaid audit consultants and attorneys play different roles in an audit, and privilege over a consultant's work depends on how t…
Local Coverage Determinations: How MACs Use LCDs in an Audit
A Medicare audit denial citing a Local Coverage Determination turns on which policy version applied, how a MAC checked it claim by…
Hospice Billing Privilege Revocations and Payment Suspensions
CMS payment suspensions, billing-privilege revocations, heightened oversight of new hospices, and the current enrollment moratoriu…
Employing an Excluded Individual: Repayment and Self-Disclosure
A screening hit on OIG's exclusion list starts a clock. Here is how to remove the person, scope the exposure, and choose between r…