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Results In Action

Since 2006, The van Halem Group has worked with a variety of healthcare providers including HME and DME suppliers, complex rehab suppliers, O&P practitioners, physicians, labs, and law firms on healthcare claim audits, appeals for denied claims, and provided education and training on compliance. Here are just some of the results we’ve been able to provide.


Big Win

We received an ALJ Decision on a case we have been working on since 2013. It was an extrapolated UPIC overpayment of over $10 million, which is one of the largest that we have worked on. Our client had a team of attorneys in addition to our team working on this for the last 7 years. There were 66 claims in question. On the day of the hearing, the judge cut the hearing short and asked us to submit a written post-hearing brief outlining our arguments. It was a lot of work, but we pulled together a 138-page document outlining arguments for every claim. In the end, the judge ruled that the extrapolation was valid….but when it came to the claims, he overturned 63 of the 66 claims. With an error rate that low, the contractor will not re-extrapolate the overpayment and in the end, our client will end up refunding 3 claims with an overpayment below $1,000.  From $10 million to less than $1000.  Incredible.

 

0% Error Rate

“Here are the results of our latest Medicaid audit of the HCPC codes you have been auditing. We got a 0% error rate.  Since we’ve been utilizing The van Halem Group services, we’ve gone from 28% error rate in 2018 to about 2% in 2019 to 0% in 2020.  I want to thank you and your staff for your assistance on this and let you know of the good outcome.”

 

Reduction in Overpayment

Following an audit, an HME business was left with an overpayment in the amount of $151,823.27. Although the denials were only related to technical issues and not medical necessity, our appeals consultant was faced with the tedious task of addressing each denial on nearly 350 claim line items. With her hard work and detailed approach, we were able to reduce the overpayment to $14,263.35 with 294 claim lines overturned, only 49 upheld, and 3 partially upheld.

 

57% Decrease in Overpayment

A physician practice on the east coast underwent a Medicaid audit on their evaluation and management services, which resulted in an initial overpayment of $406,481 due. Working with the practice’s legal counsel, our clinicians conducted an independent review of the findings and drafted an independent report. And while we agreed with some of the findings, we disagreed with many of them. After reviewing our final report, the overpayment was reduced to $173,519, a 57% decrease! And the practice was still afforded appeal rights to pursue the opportunity for further decreases in overpayments.

 

From $500,000 to $13,000


 

In 2013, an HME client received an overpayment demand back for nearly $500,000. The owner of the business setup a repayment plan and refunded the money. Our team took on the task of fighting the overpayment and successfully reduced the amount due to $223,000 during the first levels of appeal. Sadly, the owner passed away shortly after; however, the new owners wanted to see the outcome through to the ALJ level. At the hearing, we conceded some of the lower dollar claims but fought the high dollar complex rehab chairs and won all but one. The new owners received a check in the amount of nearly $210,000, and our efforts resulted in the overpayment demand being reduced from $500,000 to $13,000.

 


We would love to work for you. Contact us today to find out how we can help your business.

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