Results In Action

For the last several years, one of our clients has been battling a well-known commercial insurer on the results of an audit that identified overpayments in excess of $5 million primarily for incorrect coding and what they determined to be inappropriate billing patterns.  Our client disagreed and engaged a law firm to assist them. After years of going back and forth, it was at a standstill with the insurer threatening a potential $16 million overpayment and holding about $8 million in payments to them. The attorneys for each side eventually agreed to go into arbitration for the original $5 million overpayment. That is when the law firm engaged vHG to provide expert consulting services on behalf of our client during the arbitration.

The hearing was conducted by a panel of three judges and we recently found out they ruled in favor of our client. The payer was not able to pursue the overpayment of $5 million against our client. 

We have been working with a home health agency in Texas on a ZPIC audit since 2014. The audit started with a 49-claim sample, of which the ZPIC denied 48. The original overpayment demand was for a whopping $5.75 million. Through the Redetermination and Reconsideration, we got 13 claims reversed, leaving 35 we appealed to the ALJ. This week we got the decision in this appeal. Out of 35 claims left in question, the judge overturned 28 of them. The overpayment was reduced to $477,000.  A total savings of $5,273,000!

A VGM member out of Louisiana received a documentation request from a Medicaid Managed Care Plan. It was multiple patients and potentially over 130 claims that could be in question. Our client turned to Sandra to assist in the response to the auditor. She compiled the documentation, reviewed it, provided feedback and once she felt comfortable with it, she submitted it on their behalf. We recently received notification that there would be no recoup of any claims and they were closing the audit. Anyone that does this type of work knows what an accomplishment that is. It simply does not occur very often. Great work, Sandra!

While we often share stories of big monetary wins, the little things often matter so much to our clients. The customer service we give our clients is unmatched. They come to us in times of turmoil, confusion, and uncertainty. We remain calm and provide sound counsel and support.  A long-time VGM member recently shared with us how helpful and supportive Kathy has been to him during some recent audits and she was always there to lend an ear.

Recently, a small OPGA member from rural Kentucky that we have worked with for many years sent a note to Natasha, who has been helping coordinate all of her upcoming ALJ Hearings saying, “Thanks so much for helping with getting everything together for us. I appreciate you.”  Three little words. I appreciate you.  It’s great to hear that our clients appreciate the work we do and the customer service we provide. Great work, Natasha and Kathy!

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.

“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.”

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.

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.

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.