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Hospice Medicare Audits

Strategies for success every step of the way.

The alphabet soup of Medicare audits has expanded over the years, and the Hospice Audit team has seen them all. Unified Program Integrity Contractor (UPIC), Supplemental Medical Review Contractor (SMRC), Center for Program Integrity (CPI), Targeted Probe and Educate (TPE) and Medicare Administrative Contractor (MAC) medical reviews demand a thoughtful and forceful response from hospices. The Hospice Audit team defends hospices each step of the way, from the initial record request through the entire 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 the expertise and 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: Record 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: Request for redetermination

Receiving audit results triggers the audit appeal process, which begins with a request for redetermination. The Hospice Audit team springs into action:

  • Audit results analysis: The Hospice Audit team has developed a sophisticated tool that allows it to deconstruct audit results 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:
    • Expediting appeals to halt recoupment
    • 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.
  • Redetermination request: The Hospice Audit team prepares a redetermination request letter that synthesizes the clinical, documentation-based, statistical and legal arguments into a compelling appeal document.

Stage 3: Request for reconsideration

A request for reconsideration is available to appeal any claims that remain denied following the redetermination decision. At this critical stage, the Hospice Audit team enhances the hospice’s appeal position in light of that decision:

  • Redetermination decision analysis: The Hospice Audit team uses its analytical tools and its extensive audit experience to break down the redetermination decision, identify weaknesses in the decision, marshal additional facts and identify new arguments specifically to address the redetermination decision.
  • Reconsideration request: The Hospice Audit team prepares a reconsideration request letter that synthesizes the enhanced clinical, documentation-based, statistical and legal arguments into a compelling appeal document.
  • Settlement opportunities: Certain jurisdictions, such as those where C2C Innovative Solutions Inc. is the Qualified Independent Contractor (QIC), have established a Telephone Discussion and Reopening Process Demonstration project in which appeals can be the subject of informal settlement discussions at the reconsideration stage. The Hospice Audit team has represented hospices in that process and have achieved over 90 percent reductions in overpayment amounts.

Stage 4: Request for Administrative Law Judge hearing

After reconsideration, the next and most significant step in the appeal process is to seek an Administrative Law Judge (ALJ) hearing. These hearings are the first and only time the hospice is able to present live testimony to a neutral adjudicator. The Hospice Audit team has significant success at this stage.

  • 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 ALJ’s 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 the Settlement Conference Facilitation (SCF) process. The SCF process is informal, and hospices often can obtain discounts on alleged overpayment amounts and avoid the time and expense of an ALJ hearing.

Stage 5: Appeal to Medicare Appeals Council

ALJ decisions can be appealed to the Medicare Appeals Council. Hospices represented by the Audit team in prior appeal stages typically do not need to seek relief from the Council, given success at prior stage. Rather, the Hospice Audit team is engaged by a hospice for the first time at this stage of the appeal process. The appeal to the Council requires careful attention to narrowing and focusing key arguments, and knowledge of what arguments the Council will favor. The Hospice Audit team has experience in taking matters to the Council, and honing an appeal for that purpose.

Stage 6: Appeal to Federal Court

The final stage of an audit appeal is to seek review of the prior decisions by a Federal District Court. The Hospice Audit team’s seasoned litigators have extensive Federal Court experience. Paired with their unmatched knowledge and proficiency in hospice matters, the Hospice Audit team is the natural choice to continue the fight at the highest levels.

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