For home care providers, medical appeal can be very expensive.
As they navigate the medical appeal process, home clinics and legal teams must work in Lockstep to achieve successful results and avoid financial blows, industry experts said in a presentation at the 2025 Alliance Financial Summit on Tuesday.
According to Bill Dombi, senior adviser at Arnall Golden Gregory Law Firm, ROI should be the biggest determinant when deciding on an appeal. He previously served as president of the National Care Alliance at home.
“There's an example where I gave a $5,000 appeal, and there's a $20,000 example,” he said. “That's not a structured situation. The time that lawyers put into this and the cost of expert witnesses can easily exceed $20,000 in what could be a very simple matter.”
Despite the large costs that could potentially add up to the appeal of healthcare, grasping ROI can go beyond dollars and cents. For example, if the provider is going through the Medicare Target Probe and Education (TPE) audit process.
“It won't take long for you to get to the point and get there. We're going to continue to fail from the TPE and begin revoking the privileges of Medicare claims,” Dombi said. “We are going to cut you off financially at the knee. When there is a revocation of the claim privilege, the legitimate process and your protection will begin to decline more and more, and perhaps you will only die with the grapes as a provider. You need to take these small issues into consideration.
Once the provider decides to pursue a medical appeal, the organization must determine whether that particular case justifies the legal counsel. Not all cases justify hiring lawyers or spending money on health professionals, Dombi pointed out.
“If you handle them internally within your organization, you can be very successful in handling appeals if you handle them within your organization, if you handle them within your organization, if you handle them within your organization,” he said. “Many hospices and home health agencies take them on, but legal counsel can do a lot about these more complex and more influential issues.”
Home hygiene has several appeal systems, each with multiple steps.
Providers seeking assistance in the direct processing of appeals throughout all stages may wish to maintain the services of their attorneys.
Alternatively, supporting and developing the internal appeal process in a home healthcare company is another role that lawyers can play. This means training people within the organization in how to handle these appeals. Attorneys can even create “decision trees” that will help them decide which cases will retain legal counsel throughout the process, Dombi noted.
Attorneys can also help providers manage technical aspects of the process, such as submitting evidence.
“For the past few years, CMS said the reversal rates that were embarrassing to CMS were largely due to the fact that providers had brought new records to ALJ. “Attorneys can help avoid such pitfalls.”
According to Dombi, on the clinical side, providers need to have strong documentation, leaning towards direct patient knowledge.
For the documentation, providers should be aware of high-risk triggers such as reconfiguration, treatment thresholds, PRN visits and long-term maintenance, according to Marcylle Combs, owner of MAC Legacy.
Based in Denton, Texas, MAC Legacy is a home health and hospice coding and consulting company.
Providers also need to have strong external support, Combs said.
“I can't stress enough when I need to call other experts,” she said during the presentation. “You need to call the state or national association. You need to know those people.”
Ultimately, providers should try to connect their legal and clinical capabilities to create a complete picture of the patient profile and how this patient fits that particular payer's compensation criteria.
“We must be able to clearly explain the clinical picture to make it clear, and we will support that, and we will tie the testimony to any legal compensation standard and present it in a logical way,” Combs said.
