The van Halem Group
Proactive and Reactive Capabilities
INTRODUCTION
The van Halem Group [“vHG”] is a healthcare consultancy based in Atlanta, GA. Founded in 2006, the firm specializes in audits, appeals, compliance, due diligence, enrollment, coding, education and other regulatory issues. The firm merged with VGM Group out of Waterloo, IA in 2014. Our team has over 250 years of healthcare experience. Our staff includes former CMS contractor or HHS employees with experience in due diligence and compliance audits, program integrity, medical and coding reviews, appeals, education, and claims processing. Our experience has enabled us to assist our clients in navigating complex regulatory issues related to our nations’ entitlement programs as well as managed care and commercial insurance plans. Since 2006, we have saved our clients over $130 million in claim overpayments and denials. We work with many types of healthcare providers, both proactively and reactively, and collaborate with key government stakeholders in a variety of projects. We also operate as an Independent Review Organization (IRO) in support of Corporate Integrity Agreements.
MANAGEMENT TEAM
For full bios of our team, visit our website at http://www.vanhalemgroup.com/meetourteam
CAPABILITIES
The following pages include a summary of the proactive and reactive services that The van Halem Group offers our clients in the post-acute care market.
Wayne van Halem, CFE, AHFI President
Carrie Nienberg, RN, CPC Director, Clinical Operations
Kelly Grahovac General Manager
Monthly Compliance Packages
As you may be aware, the Office of Inspector General (OIG) requires providers submitting claims to the Medicare program to have a Compliance Program that meets government expectations and has indicated that not doing so in today’s environment is considered negligent. OIG’s authority was also recently expanded to include the ability to exclude a provider who has had compliance issues, but does not have a comprehensive compliance program, as they pose a risk to the Trust Fund. We have extensive experience in providing services to augment or enhance your existing compliance program so that it meets these requirements. These services are designed to assist your compliance officer in integrating each of the required elements of an effective compliance program. We have provided multiple options below for consideration. Each location’s audit results will be tracked and each quarterly Executive Summary will be provided to the Compliance Officer and senior leadership. The reports will include benchmarking with locations and if there is an identified area of risk within the quarterly audit, it can be addressed with specific education, training or corrective action plan. If necessary, an additional claims audit can be performed to ensure the corrective actions have been effective.
The monthly packages include:
• Access to customized Compliance Policy and Procedure Manual
• User licenses for custom online compliance training with management reporting and tracking
• Quarterly random sample generation
• Technical and Clinical review to ensure compliance in coding, billing and medical necessity
• Quarterly Audit Reports per location with benchmarking
• Compliance consultations, corrective action plans, and quarterly education following audits
• Anonymous Compliance Hotline (Telephone and Web-based) for all employees
• Compliance literature for all locations
• Quarterly compliance newsletter
• Discounted rates on reactive services
Our compliance packages are broken down into four tiers, from Bronze to Platinum and can be customized to best meet your needs. Pricing is based on package tier and varies based on number of locations and employees. Each package can be customized to meet your specific needs.
Quarterly or Singular Proactive Desk Audits
If you are not interested in a monthly compliance package, vHG can also perform on-going quarterly audits or a one-time desk audit. Our staff will assist in identifying a universe of claims, choose a random sample, and request specific documentation. The entire process is accomplished electronically without need for an on-site visit. Once a comprehensive
clinical, coding, and technical review is performed, an Executive Summary is drafted and provided. Once reviewed, a follow-up education and training session is scheduled with appropriate staff members.
Clinical Prescreens
The van Halem Group’s team of expert clinicians can review your documentation prior to dispensing to determine if all coverage requirements have been met, reducing the risk of claim denials or overpayments. Our reviews are designed to not only provide you with valuable information but can also be used as an educational tool for your referral sources. As an independent clinical reviewer, our recommendations and clinical insight will benefit your referral sources. By utilizing The van Halem Group’s clinical prescreen services, you can rest assured that your documentation supports the services you provide.
HIPAA Compliance Program
HIPAA, the Health Insurance Portability and Accountability Act, sets the standard for protecting sensitive patient data. Any company that deals with protected health information (PHI) must ensure that all required physical, network and process security measures are in place and are followed. The OCR will be targeting both covered entities (CAs) and their business associates (BAs) to evaluate their ability to meet selected standards and implementation specifications. The van Halem Group offers a comprehensive HIPAA security assessment and compliance program dashboard, called HIPAAwise, which includes the following:
• Quarterly HIPAA Security Training and Awareness Program with reporting and tracking
• Comprehensive Security Risk Assessment
• Policies and procedures as directed by HIPAA
• Breach management
• Business Associate Agreement management (with electronic signature capability)
• Inventory and location tracking
• Comprehensive reference library
All of this is provided via an easy-to-use “smartsheet” dashboard which enables our clients to implement and maintain a comprehensive HIPAA compliance program in one location. In the event of an audit, the system provides everything you need to successfully navigate through it.
Reactive Audit, Appeal, and Arbitration Support Services
Navigating the turbulent waters of changing healthcare regulations requires a hands-on approach. Having worked directly for Medicare contractors in the areas of Medical Review, Program Integrity, and Appeals, our team has unique insight to assist with every step of the audit response process, 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
• Six-Year Lookback Audits
• Due Diligence Audits
Our staff, which includes clinical, audit, and statistical experts, 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, extrapolated overpayments.
PDAC Verification Requests, Reimbursement Strategy and New Product Coding
Submitting a request to the PDAC for coding can be a complicated process. The van Halem Group makes it simple. Our team of experts, including the former Medical Director of the PDAC, can evaluate your products and determine the appropriate HCPCS codes to submit for PDAC verification and complete and submit the application on your behalf. Tried it once and received a rejection? Let our team help make the necessary corrections and work to get an assigned HCPCS code for your product. The van Halem Group can also assist both distributors and manufacturers in developing a reimbursement and coding strategy for new products.
Compliance Program Assessments
Our team can perform a comprehensive assessment of your internal compliance program to identify best practices and/or areas for improvement. Our assessment is based upon the US Department of Justice’s “Evaluation of Corporate
Compliance Programs” and it includes over 50 unique measures in 12 different categories designed to answer the following basic questions:
1. Is the corporation’s compliance program well-designed?
2. Is the program being applied earnestly and in good faith? In other words, is the program adequately resourced and empowered to function properly?
3. Does the corporation’s compliance program work in practice?
Process Assessments
As a new or even an existing provider, you want to make sure the processes you create align with industry standards. Our expert team of consultants have analyzed processes for large and small providers throughout the country. The process includes an on-site or virtual review of any of the following areas:
• Workflow
• Intake
• Documentation Management
• Billing
• Denial management
As part of our review, you will receive a comprehensive Executive Summary which would include a summary of potential vulnerabilities, suggestions for necessary or recommended corrective actions or improvements, as well as best practices.
Accreditation and Provider Enrollment
Prior to beginning the DMEPOS enrollment process, a supplier needs to obtain their accreditation through one of the CMSapproved accrediting organizations. Our consultants will ensure your business meets the required DMEPOS Quality Standards. Following accreditation approval, The van Halem Group can provide Medicare PECOS enrollment, revalidation, and process updates, making sure you enroll correctly to bill Medicare and avoid potentially costly revocations or supplier standard violations. We also provide assistance with Medicaid enrollment and revalidations as well.
Education and Training
The van Halem Group’s team of expert consultants are able to train your employees on proper documentation requirements and coverage criteria to make sure claims are filed correctly the first time, so you can get paid and keep your money in the event of an audit. Training is available for Medicare, Medicaid, and third-party payers.
General Consulting & Collaboration
For over 20 years, The van Halem Group team has been building and developing strong and collaborative relationships with key industry stakeholders. Our team is widely recognized as industry thought leaders. We have staff that actively participates in numerous boards, councils, and stakeholder groups, including:
• American Association for Homecare Regulatory Council
• Medtrade Educational Advisory Board
• Medicare MAC Jurisdictional Councils
• State Association Boards
• National Supplier Clearinghouse (NSC) Advisory Council
• HME Business Advisory Board
• VGM Government Relations
• Board of Directors of Friends of Disabled Adults and Children
With these groups and singularly, our team regularly meets and interacts with other industry experts and representatives from a wide variety of federal and state entities, including:
• Centers for Medicare and Medicaid Services (CMS)
• Medicare Administrative Contractors (MACs)
• Recovery Audit Contractors (RACs)
• Unified Program Integrity Contractors (UPICs)
• Supplemental Medical Review Contractors (SMRC)
• Health and Human Services Office of Inspector General (HHS OIG)
• United States Department of Justice (US DOJ)
• Pricing, Data Analysis and Coding Contractor (PDAC)
• National Supplier Clearinghouse (NSC)
• State Medicaid Programs
These relationships have uniquely positioned us as a valuable resource for our clients as we are successful in leveraging them to resolve on-going issues, achieve specified outcomes, obtain clarification on existing rules, or affect changes in healthcare policy and benefit categories. Our team also stays abreast of the ever-changing rules and policies that impact our clients – helping them avoiding unnecessary compliance issues.
We appreciate the opportunity to present a summary of the services that we offer our clients. For pricing information or to discuss in more detail, please feel free to contact our office at (404) 343-1815 or via email at Info@vanHalemGroup.com. We are confident we can work together to reach your goals!