The Recovery Audit Contractor (RAC) program was designed to identify and correct Medicare improper payments, but for years it operated as a blunt instrument—one that too often punished compliant providers while rewarding aggressive, error-prone auditing. It still does. But in recent years, CMS has implemented teeny tiny reforms that acknowledge these imbalances. Yet for hospitals
The Absurdity of Boilerplate RAC Audit Denials: A Due Process Problem Hiding in Plain Sight
RACs and UPICs have become one of the most burdensome—and least accountable—mechanisms in the Medicare reimbursement system. Armed with contingency-fee arrangements that incentivize denials over accuracy, RACs and UPICs routinely issue claim denials resting on language so vague and conclusory that providers are left shadowboxing against accusations they cannot meaningfully identify, let alone rebut. The
Pay Me What You Owe Me!: Why Medicare Providers Should Stop Waiting and Start Litigating
Under 42 C.F.R. § 422.214(a)(1), a noncontract provider that furnishes services to an MA enrollee must accept as payment in full:
“the amounts that the provider could collect if the beneficiary were enrolled in original Medicare.”
I read that to mean that a provider of Medicare Advantage services will be reimbursed like original Medicare. I know
Knicole Emanuel Joins Poyner Spruill!
Escalating Medicare Provider Audits to Federal District Court: When and Why It Matters
Medicare providers facing adverse audit determinations often navigate a lengthy administrative appeals process before obtaining meaningful judicial review. While many appeals are resolved within the Centers for Medicare & Medicaid Services (CMS) administrative framework, providers should understand that federal law allows certain appeals to be escalated to a United States District Court when administrative deadlines
CMS Proposes Stronger Medicare Integrity Measures While Expanding Support for Home Health Providers
The Centers for Medicare & Medicaid Services (CMS) has unveiled its proposed Calendar Year (CY) 2027 Home Health Prospective Payment System (PPS) rule, combining tougher enforcement against fraud with payment increases and policy changes designed to strengthen access to home health services. The proposal reflects a dual focus: protecting the Medicare Trust Fund while supporting
(In)Justice Without Witnesses: Lack of Procedural Due Process in Medicare Provider Appeals
The Centers for Medicare & Medicaid Services (CMS) rely upon private contractors to investigate providers, identify alleged overpayments, revoke Medicare enrollment, and impose sanctions carrying enormous financial and professional consequences. Although these proceedings are classified as civil administrative actions, they increasingly resemble prosecutorial enforcement while lacking many of the procedural safeguards traditionally associated with adjudication.
If Medicare Knows Inflation Is Real, Why Doesn’t Physician Payment Reflect It?
My sister, mom, and I drove to UNC-W over the weekend. My only daughter Madison turned 21 this past Thursday, and the family celebrated over the weekend. Needless to say, I had a fantastic few days. Unfortunately, coming back to Monday morning news is not always as enjoyable. Wasn’t it Garfield who famously said, “I
$3.26 Million Recovered? Not So Fast: How a Florida Wound Care Clinic Turned a Medicare Overpayment Demand Into a Complete Victory
When Medicare contractors demanded that a Florida wound care clinic repay $3,261,046.50 for claims involving skin substitute grafts, the government’s position seemed clear: the products were allegedly “investigational,” “experimental,” and therefore not payable under Medicare.
The Administrative Law Judge (ALJ) disagreed.
In a fully favorable February 2026 decision, the ALJ overturned the entire overpayment demand,
Medicare Advantage Plans Overturned Nearly All Appealed Skilled Nursing Facility Denials, OIG Finds!
Does your facility appeal recipient admission denials? Want to increase revenue and help consumers receive medically necessary health care services? Appeal consumer admission denials. A new report from the U.S. Department of Health and Human Services Office of Inspector General (OIG) has raised significant concerns about how Medicare Advantage organizations (MAOs) handle prior authorization requests