HLS has a successful track record defending audits and appealing audited claims from Medicare, Medicaid, and insurance audit contractors. Once the provider gets notice of an audit, even if it is for a simple documentation request, we propose that the provider be proactive and start making its case from the very beginning to save time and to expedite payment. Healthcare providers usually hire nursing and coding specialists to appeal audits and conduct chart reviews. With HLS, in addition to clinical and coding knowledge, we can add an additional legal layer to appeals to set the tone and to narrow down the issues being audited. If the appeal is denied at the initial level, HLS can appeal at the next level which is often court or arbitration, or before a contractor.
With an early HLS intervention, our clients have a shortened audit cycle. HLS has been able to salvage audited accounts even after accounts funds have been recouped.
RAC, MAC & QIO
Sample projects:
- Medicare denials – outpatient and inpatient
- Medicare – Medicaid Audits
- Coding downgrades
- RAC, ALJ, ADR
HLS handles administrative appeals in all stages of the governmental payer appeals process. These processes include Recovery Audit Program (RAC), Medicare Administrative Contractor (MAC), and Quality Improvement Organization (QIO). HLS’s approach combines legal and clinical argumentation. Our combined knowledge of the Social Security Act, Code of Federal Regulation, and Center for Medicare and Medicaid Services (CMS) Manual and Ruling guidance results in unmatched appeal outcomes. A business relationship with HLS allows for a coordinated process with the hospital’s case management, compliance, and legal departments.