Reactive Services
Knowledge. Experience. Results.
Navigating the turbulent waters of changing healthcare regulations requires a hands-on approach. Having worked directly for Medicare contractors, our team has unique insight to assist with every step of the audit response process. We work collaboratively with key stakeholders to address your audit and appeal challenges, including:
- Medicare audits:
- Recovery Audit Contractor (RAC)
- Unified Program Integrity Contractor (UPIC)
- Supplemental Medical Review Contractor (SMRC)
- Targeted Probe and Education (TPE)
- Comprehensive Error Rate Testing (CERT)
- Medicaid audits
- Medicare/Medicaid Advantage audits
- Commercial Plans and other Private Payer audits
- Tricare and other Government Payer audits
- Office of Inspector General (OIG) audits
Our staff has the unique knowledge and expertise that enables us to “get in the weeds” and resolve ongoing problems and issues quickly and definitively. We have the capabilities to manage and resolve single claim denials all the way to large multi-million dollar extrapolated overpayments.
ADR Response and Appeal Tracking
The van Halem Group offers several different options for the initial responses to ADR letters. These services are completely customizable, from simply tracking and reporting based upon your data to utilizing our clinical team to perform clinical reviews, each of our options comes with tailored reporting, as well as monthly analysis and educational consults. We have made significant investments in technology solutions that enables us to automate the process and communicate electronically directly with Medicare.
Pricing varies depending on the options chosen.
Appeal Preparation
We provide appeal preparation services for your denied claims. For medical necessity denials, an expert Clinical Consultant team member will draft a summary of the documentation that supports that the services are reasonable and necessary. If additional documentation is necessary, our Medical Records team can collect on your behalf. If the denial is unrelated to medical necessity, an Appeal Coordinator will draft an appeal specifically addressing the denial reasons noted. Our staff will manage the process all the way through the Medicare Appeals Council, if necessary. It is important to note that our staff does not simply submit an appeal request, they address the specific denial reasons.
Corrective Action Plans
The van Halem Group can prepare a Corrective Action Plan (CAP) based on discoveries made during an audit, or in mandatory situations when requested by the MAC or other government entity. The CAP will identify the compliance risk, detail the corrective measures taken to avoid future risk, and include timelines and expected outcomes.
Sampling Methodology and Extrapolation Review
The van Halem Group works in conjunction with qualified statisticians on large, extrapolated overpayment cases. Our statisticians are doctorate level professionals familiar with multiple sampling methodologies and extrapolation processes. Our statisticians work to disqualify the methodologies used by contractors and compose comprehensive reports to justify their findings. We have experienced much success in reducing or eliminating multi-million dollar extrapolations with a combination of detailed appeals and statistical analysis.
Education and Training
All work performed by our team includes an educational component for our clients. Our clinical staff reviews patient files and drafts a summary of the documentation presented for use with ADR responses or appeals but also identifies potential issues and recommendations for our clients. Our clinical staff compiles data regarding their reviews and provides regular feedback to our clients. We offer additional education and training opportunities, including on-site training, webinars, checklists and written reports as necessary. All education and training is offered with the expressed goal of reducing unnecessary denials and overpayments.
OIG Six Year Look-back Audit Response
Recently, the Office of the Inspector General (OIG) has begun instructing providers and suppliers to conduct claims review for the previous years billed, for up to six years prior. The reviews must include all claims in the six year period that meet the parameters, or require statistical sampling to determine a universe of claims for review. Look-back reviews can be burdensome and require an expert statistician.
The van Halem Group will work in conjunction with your legal counsel and our doctorate level statisticians to provide an accurate and thorough audit response. In addition to statistical analysis, our clinical experts will conduct a review of the identified claims to determine coverage and documentation requirements are met.
The pricing for reactive services is based upon each individual project and can be retainer, hourly, project fee or per file fees. Payment options are presented based upon project.
Revocation Assistance
Compliance with supplier standards is essential to protect your Medicare enrollment and payor agreements. Revocation of your billing privileges, exclusion from the Medicare and Medicaid programs, and even denials to enrollment are all potential outcomes a provider can encounter if they fail to report changes or update required information.
The van Halem Group is committed to offering services that address these concerns and protect your organization. Our team of experts can help you manage your provider enrollment, address, and resolve compliance and audit issues, and even provide education and training to your staff so that they better understand the importance of properly managing licensure and accreditation.
And if your organization is in trouble, we can help! Our team can develop a corrective action plan (CAP) to correct identified deficiencies and, when appropriate, submit a Reconsideration to the provider enrollment contractor.