Imagine a prosecutor who files charges, seizes the defendant’s assets before trial, and then never appears in court. No opening statement, no witnesses, no cross-examination. The defendant hires counsel, assembles the record, and argues to an empty table while the charging document sits in the file as though it proves itself. In any criminal court,
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Medicare Audit Pressure Intensifies: CMS’s Newest RAC and UPIC Policies and Targets
Federal Medicare enforcement continues to accelerate. CMS seems to be deploying more contractors, broader audit authority, and sharper analytics than at any point in the program’s history. Always be on the lookout.
The Enforcement Backdrop
CMS reports total program-integrity savings rose 59 percent, from $26.3 billion in FY 2024 to $41.9 billion in FY 2025.…
Another Win with a TRO Lifting a Medicaid Suspension!
I want to celebrate a recent win and provide a warning.
When a state agency suspends a healthcare provider’s Medicaid payments, the consequences can be swift and devastating — especially for practices that serve the most vulnerable patient populations. In August, an Administrative Law Judge in North Carolina issued a decisive Temporary Restraining Order for…
The Denials That Keep Coming Back: A Provider’s Guide to the Most Common Medicare Claim Rejections
Every provider who bills Medicare has felt the sting of a denied claim. Some denials are one-off mistakes — a transposed digit, a missed modifier. But others show up with frustrating regularity, draining revenue, consuming staff hours, and delaying payment for care that was unquestionably delivered. Understanding the most common denial patterns is the first…
The Government Is Coming for Your Wound Care Practice — Here’s Why They’re Wrong and How Providers Are Fighting Back
The government has wound care in its crosshairs. The HHS Office of Inspector General published a September 2025 report titled Medicare Part B Payment Trends for Skin Substitutes Raise Major Concerns About Fraud, Waste, and Abuse, declaring that Medicare Part B expenditures for skin substitutes “have skyrocketed,” surpassing $10 billion annually by the end of…
When the Audit Letter Becomes a Threat: What Providers Need to Know About MCO, RAC, and UPIC Audits That Escalate to Government Investigations
It usually starts with a letter. A managed care organization (MCO), a Recovery Audit Contractor (RAC), or a Unified Program Integrity Contractor (UPIC) notifies your practice that it has completed an audit and determined that you owe a significant overpayment—sometimes hundreds of thousands of dollars. That alone is alarming. But buried in the fine print…
$1.6 Billion in Medicare Fraud Stopped: What CMS’s Lab Crackdown Means for Legitimate Providers
The numbers are hard to ignore. The use of AI has substantially increased the number of audits over health care providers. Hence, the increase of amount of money found to be noncompliant. Since the start of the current administration, the Centers for Medicare & Medicaid Services (CMS) has blocked more than $1.6 billion in potentially…
Groundbreaking Case for Medicare Reimbursement!!
In Home Health, LLC v. Robert F. Kennedy, Jr., No. 25-3542 (6th Cir. July 27, 2026). Published for Binding Precedent per Sixth Circuit I.O.P. 32.1(b).
I. Introduction
On July 27, 2026, the United States Court of Appeals for the Sixth Circuit issued a groundbreaking decision in In Home Health, LLC v. Robert F. Kennedy, Jr.,…
Updated Recovery Audit Contractor (RAC) Program Report
The Centers for Medicare & Medicaid Services (CMS) Medicare Fee-for-Service Recovery Audit Program continues to operate through contracted Recovery Audit Contractors (RACs) across five designated regions nationwide. The RAC Program is designed to identify and correct improper payments—both overpayments and underpayments—made to healthcare providers under Medicare Parts A and B. I am going to provide…
Recovery Audit Contractor Reforms: Teeny Tiny Progress Made, But Providers Deserve More
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…