Search Results for: Special Investigations Unit

Recent Developments in Personal Care & Community-Based Services in Medicaid and Medicare

Home Health & Hospice /

(March 23, 2020): Until recently, personal care services, such as home health aides, were not covered under the Medicare program unless they were part of a skilled service where the beneficiary was homebound.  However, beginning with calendar year 2019, the Medicare program has expanded the ability of plans that participate in the Medicare Advantage program […]

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Overview of Dental Claims Audits and Investigations by Medicaid and Private Payors in 2019

Dental Audits & Compliance /

(March 4, 2020): Many dentists and dental practices around the country are glad that 2019 is behind us.  Last year was a banner year for law enforcement investigators and administrative auditors of dental claims.  Federal and State prosecutors around the country actively pursued both civil and criminal cases against individual dentists for a variety of

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Investigations of Medicaid Dental Fraud in Texas

Dental Audits & Compliance /

(July 1, 2014): Law enforcement authorities are actively investigating and prosecuting health care providers for crimes based upon allegations of Medicaid dental fraud in Texas. When looking for fake billing to the Medicaid program, investigators have historically targeted hospitals and doctors, but increasingly dentists have come under watch. In Texas, new measures have been adopted

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Personal Care Service Agencies and Personal Care Service Attendants are Increasingly Targeted in Medicaid Fraud Investigations

Medicare, Medicaid & Private Payor Updates /

(September 15, 2023): Medicaid funding for personal care services allows those that need help for activities of daily living to remain in their homes and receive care from qualified individuals rather than have to live in institutional settings.[1] This is also a benefit to Medicaid, as it reduces the demand and costs for institutional and

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SIU Dental Audit Reviews by DentaQuest, Delta Dental and Cigna Can Ultimately Lead to Criminal Prosecution and Imprisonment.  Are Your Dental Office’s Medical Necessity, Documentation, Coding and Billing Practices Compliant?

Dental Audits & Compliance /

(October 16, 2019): A Federal District Court Judge recently sentenced a Murfreesboro, TN dentist to prison and ordered that he pay restitution to TennCare (Tennessee’s Medicaid program). Regrettably, the types of improper billing practices cited by the government in the criminal Information filed against the defendant dentist aren’t that uncommon. This recent prosecution serves as

SIU Dental Audit Reviews by DentaQuest, Delta Dental and Cigna Can Ultimately Lead to Criminal Prosecution and Imprisonment.  Are Your Dental Office’s Medical Necessity, Documentation, Coding and Billing Practices Compliant? Read More »

Aetna’s SIU is Actively Auditing Dental Claims. Are Your Dental Services Compliant with Applicable Regulatory and Contractual Requirements?

Dental Audits & Compliance /

(January 3, 2019): Slowly but surely, the percentage of adults and children with dental insurance coverage benefits has gradually climbed. These increases have been driven, at least in part, by several factors. First, despite the fact that traditional Medicare does not cover routine dental services, a number of Medicare Advantage plans are now offering coverage

Aetna’s SIU is Actively Auditing Dental Claims. Are Your Dental Services Compliant with Applicable Regulatory and Contractual Requirements? Read More »

Delta Dental Audits Will Increase in 2026. Is Your Practice Ready? - Featured Image - Liles Parker

Delta Dental Audits Will Increase in 2026. Is Your Practice Ready?

Medicare, Medicaid & Private Payor Updates /

(January 13, 2026): As the great Yogi Berra once said, “It’s tough to make predictions – especially about the future.” This maxim is especially true when it comes to forecasting the specific dental claim risk issues that will be the focus of private payor Special Investigation Units (SIUs) in 2026. Nevertheless, we are going to

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Responding to Medicare Audits of PCR Testing for UTIs in 2026 - Liles Parker

Responding to Medicare Audits of PCR Testing for UTIs in 2026

Medicare, Medicaid & Private Payor Updates /

(December 18, 2025): Laboratory Polymerase Chain Reaction (PCR) testing for urinary tract infections (UTIs) offers rapid, sensitive pathogen detection but often presents complex coding and billing challenges for Medicare providers and laboratories. Medicare contractors are increasingly denying UTI test claims due to issues with medical necessity, documentation, and improper coding/billing practices. Robust compliance and up-to-date

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Wound care aukdit and skin substitute audit 2026 - Featured Image - Liles Parker

Responding to Wound Care Audits and Skin Substitute Audits in 2026

Medicare, Medicaid & Private Payor Updates, Other /

CMS UPDATE – DECEMBER 24, 2025 “Effective immediately, CMS’ A/B Medicare Administrative Contractors (MACs) are withdrawing the Local Coverage Determinations (LCDs) for Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers that were scheduled to become effective on January 1, 2026.” ORIGINAL ARTICLE (December 11, 2025): In 1789,

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