RECOVERY AND APPEALS SERVICES
Gateway Home Health Consulting experts apply knowledge of Medicare / Medicaid Local Coverage Determinations, National Coverage Determinations, Program Integrity, Beneficiary Coverage Guidelines and other payer rules to agencies clinical documents. Our knowledge of the regulations is applied to achieve a more favorable outcome throughout the appeals process and levels.
Our knowledge is your benefit!
Our extensive experience with Administrative Law Judges across the country enable our consultants to have the most favorable overturn rates in the country. Our goal is it to provide the best representation to Agencies across the country, through one of the most taxing problems an Agency can experience.
Gateway Home Health Recovery and Appeals Consultants:
-
Use their extensive knowledge to properly format and index clinical documentation at the ADR (Additional Documentation Request) level. This includes providing recommendations to address allowable alterations, identifying missing information that would normally be included within a Home Health episode of care and providing expert opinion based on Medicare Eligibility and Coverage guidelines.
-
Manage redetermination and mid-level appeals for Medicare, Medicaid and other payer types. Utilizing Program Integrity and Benefit Policies, along with our years of experience, we are able to consistently rebut and provide evidence to support claim payment. By providing accurate rebuttals we are able to further increase the success rate moving towards ALJ.
-
Represent our clients with great success at the ALJ (Administrative Law Judge) level. Our consultants have prepared filings and represented providers under the following programs; Zone Program Integrity (ZPIC), Benefit Integrity and Recovery Audit Contract (RAC), Unified Program Integrity Contractor (UPIC), Targeted Probe and Educate (TPE), Third Party Liability (TPL) and more.
Appeal Processing
Both agency and Gateway coordinate efforts for timely and accurate responses throughout the medical review process and appeals system. For example, Medicare includes the following process…
Medical Review Additional Documentation Requests (ADRs)
Redetermination (First Level)
Reconsideration (Second Level)
Administrative Law Judge Hearing (Third Level)
Appeals Council Review (Fourth Level)
Judicial Review in U.S. District Court