Industry Newsmaker

Bridging Worlds

Wayne van Halem applies 11 years’ experience at Medicare to give providers audit assistance.

Wayne van Halem came to the home medical equipment industry through perhaps one of the most unlikely routes. As a onetime Medicare fraud investigator who eventually rose through CMS’s ranks to oversee DME appeals on a national basis, van Halem now runs The van Halem Group LLC, a team of ex-Medicare experts who help providers navigate CMS’s often maddening pre- and post-payment audit and appeals process.

Getting there has been an interesting journey. Van Halem literally went to work for Medicare right after graduating from the University of South Carolina, starting in the customer service area for one of the DME Medicare Administrative Contractors in Jurisdiction C taking Medicare beneficiary complaints over the phone.

“It was probably one of the worst jobs, I’ve ever had in my life,” he jokes. “But I learned an awful lot. It’s where I learned the most amount of information. When you’re constantly getting calls from providers and beneficiaries, it sort of forces you to gain a pretty intense knowledge of coverage and policies.”

Van Halem’s degree was in Criminal Justice, and his desire was to get into fraud investigation. So he stuck with the bottom-rung job for the duration of a year, in order to transfer to what CMS at the time called it’s Anti-Fraud Unit. There, he worked as a Medicare fraud analyst for a few years.

“Then I worked as a Medicare Fraud Information Specialist,” he says. “There were about 20 of us throughout the country, and we served as a liaison between law enforcement, Medicare contractors and CMS. … My jurisdiction was about half the country.”

Those three jobs — customer service, fraud analyst and fraud information specialist — gave van Halem a knowledge of resources and process, as well as contacts with contractors, CMS and law enforcement.

Then Medicare came up with a program called Program Safeguard Contractors, and van Halem was one of the first fraud investigators hired with them, where he worked in Jurisdictions A and B. Then he became a supervisor.

His last Medicare job was when CMS came out with the qualified independent contractors, where he was hired as director of DME appeals, nationally, and Part B appeals for the western region of the country.

In 2006 he struck out on his own to work with providers to educate them and using contacts to help them navigate the process. “I saw a need for working with providers,” he said. “Even when I was an analyst and an investigator for Medicare, I didn’t feel like I was using my degree in Criminal Justice and investigating fraud, as opposed to looking to see if ‘T’s were crossed and ‘I’s were dotted.”

Now van Halem and his team finally brings all those skills to bear assisting providers with audits and appeals.

“We bring a unique perspective in that we actually worked for Medicare doing these audits,” he says. “We know how the inner workings of Medicare and what the contractors’ limitations are.

“But also their position,” he adds. “A lot of people blame contractors, but they’re often between a rock and a hard place, because they have a contract with Medicare that they want to keep, and Medicare is the one that establishes the rules, but the contractors are the ones that have to deliver the message and do the work.

“But because they know us and know our background, we have a good working relationship with the contractors,” van Halem says, “That is why I think we’re able to do more than other folks can do on their own.”

As any provider knows, CMS has drastically ramped up the volume and intensity of its pre- and post-payment audits, and despite crowing about the results (see “News, Trends & Analysis, page 8), it is a program that through a high rate of appeals and overturns, as well as bad direction from contractors is clearly not working.

“It’s a broken system for sure,” he says. “I say that to my clients all the time. … One of the reasons I left Medicare was that I was so frustrated that, despite what folks think about contractors they really do have well-qualified people in some of these roles, but the focus from Medicare was always on quantity. It was never on quality. … I personally didn’t feel that providers were given a fair appeal. After a decade in a job that’s hard thing to leave, but I did see a need out there.”

In addition to helping providers handle audits, the core issue is trying to fix that broken system. To that end, van Halem says that his firm reached out to the Senate Finance Committee via a white paper that discussed the various issues with CMS’s current Medicare audit program, and why the issues existed. It then went on to make various recommendations on how the program could be improved to help providers, as well as to ensure a more efficient program that still maintained program integrity. He says that the committee took that information as well as information from other sources and its own research, and came up with a number of recommendations that it would like to see put into place.

“So, I do think that there is some sort of light at the end of the tunnel, so that they improve the process so that it is a little more reasonable for the providers,” he says. “You know, as a provider billing the government, I don’t think you are ever going to be able to get out of being audited.

“However the audit process should be fair and it should be reasonable,” he adds. “In fact the program integrity manual mandates that. And I don’t think it currently is. I don’t think the audit process is fair and I don’t think the appeal process is fair. But the fact that the people who have the power to do this — The Senate Finance Committee — have recognized that there are problems and have requested input from other stakeholders is a really good sign.”  

About the Author

David Kopf is the Publisher and Executive Editor of HME Business and DME Pharmacy magazines. Follow him on Twitter at @postacutenews.

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