ATLANTA – William E. O’Malley (pictured) worked for CMS on several different levels, even leading the Recovery Audit Contractor (RAC) program for more than a decade. O’Malley and several members of his team are bringing that insider knowledge to Medtrade East as part of Engage Health Solutions, a Pennsylvania-based company that offers consultative and technological services.

Medtrade Monday sat down with O’Malley, who serves as COO at Engage, to get a better idea about the company (a first-time exhibitor at Medtrade East) and what attendees can expect to find when they pay a visit to the Engage Health Solutions booth at the Georgia World Congress Center.

Medtrade Monday: What will people will find when they come to your booth?
O’Malley: Our goal is to ensure that there is payment accuracy from end to end in the reimbursement continuum. It starts with the suppliers where we ensure that they have all the I’s dotted and t’s crossed. We make sure their records are supportive of the equipment that they’re providing to the patient. We make sure their claims are billed correctly and they are not overcharging or undercharging for their services.

Once that claim gets dropped, we work with them to ensure that appropriate reimbursement is made. If there’s an audit or denial, we’ll take that and we’ll work those claims end to end and support those claims throughout the process. So if it’s an audit, we’ll prepare the response. We will ensure the records are sufficient and do the submissions. If it is still denied, then we will draft some appropriate and strategic appeal language for denial management purposes. We will take that all the way through the ranks from the lowest levels up to ALJ or beyond if needed.

Medtrade Monday: When did you transition from CMS to Engage?
O’Malley: In 2016, I left and I started Engage. However, one of the RAC contractors came back to me and asked if I’d run the program for them, so in late 2017 I went back and I ran the RAC program for until July of 2020. After that I left and kind of brought everybody over from the RAC side and commercial review side—and now they work for me.

Medtrade Monday: How does your RAC experience help providers?
O’Malley: With our team, we do a lot of training and education. We have a lot of guides, templates, and checklists to make sure that people are interpreting policy correctly. Many times what we saw on the audit side was either poor interpretation or poor application. Using our knowledge from the RAC experience, we’ve developed these guides that will help people not make the common mistakes and then highlight the areas that are typical denial points. We ensure that all your information is robust enough to support it through the entire reimbursement cycle.

We’ve been on the payer and provider sides and across many different payers. It’s not only CMS, which would be Medicare and Medicaid. We’ve also worked with just about every insurer that you could name in the country, whether it’s national, regional, or local.

Medtrade Monday: How would you describe your approach?
O’Malley: It’s really a consultative and technological approach. So we both technology when we have available data to scrub and run edits to determine your potential. We’ll look at claims history to analyze and determine where gaps are present and improvement opportunities are available. And then we use the consultative side to take the information that we gathered in the previous process and determine what the process improvement needs to be to correct the problem. The goal is to get that claim accurate, error free, and not repeat the same error over and over again to mitigate the exposure.

Medtrade Monday: How would you characterize the audit climate in October 2021?
O’Malley: I just got off some calls with some colleagues at CMS that I still keep in touch with. I would say that right now the climate is escalating quite substantially. Changes have been put in place recently that are going to be felt by the suppliers rather quickly. So not only are audits increasing from the RACs and MACs—TPE has started again, so that’s back on the table.

The RAC limitations are lifting, so now you see ADR numbers escalating quite rapidly. There were new civil penalties brought into play within the last few months for consistent non-compliance. Not only do you get the claim denied, but if you make the mistake enough times, now they’re going to put civil penalties on top. And there’s been an increase in DOJ activity for small suppliers such as DME folks.

You’ve probably seen recently that there’s a lot of activity with CVS, Humana, UHC. They all had DOJ actions that resulted in upwards of $20 million worth of fines. But there’s also been a lot of activity in the lower end, where you see a lot of telehealth DME suppliers—even optometrists and dentists—who are only maybe $200,000. There’s been a lot of activity. I think the consistent non-compliance demonstrates that you know that there’s a false claim in process, and if you continue to go down that path, that’s where the DOJ will step in and say you can’t do that.

Medtrade Monday: Why did you decide to exhibit at Medtrade East?
O’Malley: We work a lot with DME providers across the country. Some of our old medical directors may have even done presentations at Medtrade East in the past. As an exhibitor, we thought Medtrade East would be a great place to get in front of people.