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Hospice Medicaid Audits

Vigorous advocacy every step of the way.

Medicaid Audits involve a unique combination of federal and state authorities and processes. The Hospice Audit team has stood up to federal Medicaid auditors and fought for hospices across the country in a variety of distinct state venues, from the initial record request through the entire state appeal process.

Stage 1: Response to record request

From a handful to hundreds of claims, the scope of an audit can be intimidating and more burdensome than a hospice can manage. The Hospice Audit team, however, handles all manner of audits every day, and has developed a number of tools to make the response process more efficient and informative:

  • Tips for organizing a medical record: A well-organized medical record can effectively paint the picture of the hospice patient in a way that makes clear that the patient has a six-month prognosis. The Hospice Audit team’s tried and true organization tool takes the guesswork out of how to best prepare a medical record for an audit.
  • Patient data spreadsheet: Detecting audit trends and vulnerabilities helps inform an audit response strategy. The Hospice Audit team has developed a spreadsheet that tracks key data points relating to each audit. These data can pinpoint the target of the audit and help identify where the hospice should devote resources in its response.
  • Audit response cover letter: Records requests issued by auditors are not always clear, and a hospice’s electronic medical records (EMR) may not exactly match what the auditor is requesting. The Hospice Audit team knows how hospices operate and has troubleshot these issues in hundreds of audits. The Hospice Audit team can bring clarity to a response and eliminate wasted efforts to chase down irrelevant materials.

Stage 2: Rebuttal of Initial Draft Report

Receiving an Initial Draft Report (IDR) from the auditor triggers the opportunity for the hospice to respond to and rebut the audit findings. The Hospice Audit team springs into action:

  • IDR analysis: The Hospice Audit team has developed a sophisticated tool that allows it to deconstruct the IDR and identify the facts and arguments that will lead to success on appeal.
  • Appeal strategy: Audit results require serious attention, thoughtful decision-making and decisive action. The Hospice Audit team considers the hospice’s objectives and risk tolerance in advising hospices regarding:
    • Marshalling scarce resources in time and personnel to mount an effective appeal
    • Developing a strength assessment to guide appeal priorities and expectations
    • Using in-house or outside experts to support an appeal.
  • “Telling a Compelling Story. . .:” The core of most audit appeals is the preparation of written summaries that support each patient’s six-month prognosis. The Hospice Audit team has developed an educational tool called “Telling a Compelling Story” that is designed to help hospice physicians and staff prepare comprehensive and persuasive patient summaries.
  • Argument catalog: The Hospice Audit team has encountered hundreds of claim denial or down-coding decisions in the appeal process—there are few such decisions that the Hospice Audit team has not already addressed. The Hospice Audit team has developed a catalog of appeal arguments it has deployed over the years to efficiently and effectively address those decisions.
  • Rebuttal of the IDR: The Hospice Audit team prepares a rebuttal of the IDR that synthesizes the clinical, documentation-based, statistical and legal arguments into a compelling appeal document.

Stage 3: Challenge to Final Draft Report

Once the auditor issues a Final Draft Report (FDR), the appeal process shifts to one governed by state law. Each state may have a different appeal process, but the Hospice Audit team has extensive experience in representing hospices in multiple states and can handle any process the state requires:  

  • Desk review: Some states allow a prompt, written appeal of an FDR before the matter proceeds further in the appeal process. The Hospice Audit team scrutinizes the FDR and prepares a written appeal that synthesizes the clinical, documentation-based and legal arguments into a compelling appeal document.
  • Preliminary conference: Some states permit a prompt “live” review before a hearing officer, often a staff attorney within the state’s Medicaid Office, before the case is set for a formal Administrative Law Judge (ALJ) hearing.
  • ALJ hearing: Most state appeal processes culminate (at the administrative level) with a hearing before an ALJ. The Hospice Audit team has extensive administrative hearing experience in state Medicaid appeals:
    • Witness selection and preparation: The Hospice Audit team works with hospices to identify the witnesses (whether hospice employees or outside experts) and prepare them to testify. The Hospice Audit team has prepared hundreds of witnesses, presented extensively at conferences on witness preparation techniques and developed a witness preparation packet to streamline the process.
    • Testimony and argument preparation: The Hospice Audit team has developed a successful formula for ensuring that the testimony and arguments presented at the hearing are clear, well organized and persuasive. The Hospice Audit team prepares testimony outlines, argument summaries and written position statements to advance the hospice’s position.
    • Hearing experience: The Hospice Audit team’s experienced litigators have decades of hearing experience, know the hearing process, know how ALJs view cases and know how to present the strongest case possible.
  • Settlement opportunities: If a settlement rather than a hearing better suits the hospice’s objectives, the Hospice Audit team will fight for the hospice through any available settlement process. The Hospice Audit team has extensive experience in successfully negotiating settlement with state Medicaid officials in relation to Medicaid audits.

Stage 4: Appeal to State Court

The final stage of an audit appeal is to seek review of the FDR in State Court. Depending on the particular state, this appeal is made to a State Trial Court or the State Court of Appeals. The Hospice Audit team’s seasons litigators have extensive experience in both venues, and are the natural choice to continue the fight at the highest levels.

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