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Thought Leadership

Do You Have a Backup? Building Redundancies Into Your Written Certification Process



The hospice certification of terminal illness is one of the documents most scrutinized by Medicare contractors, and it is of critical importance since an invalid certification can impact Medicare payment for the patient’s entire 90 or 60-day benefit period. If overlooking any of the multitude of certification requirements is human, then building redundancies into your certification documentation to avoid claim denials or a repayment obligation is divine. In this episode, Husch Blackwell’s Meg Pekarske and Andrew Brenton share key ideas for putting yourself in a more favorable position in the event your best-laid written certification plans go awry.

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This transcript was auto-generated using Adobe Premiere Pro.

00:00:05:00 - 00:00:18:03
Meg Pekarske
Hello and welcome to Hospice Inights, The Law and Beyond where we connect you to what matters in the ever changing world of hospice and palliative care. Welcome, Andrew. It's great to see you. Thanks for taking the time.

00:00:18:23 - 00:00:20:09
Andrew Brenton
Yeah, happy to be here.

00:00:20:21 - 00:01:24:02
Meg Pekarske
So we're talking today about building in redundancies and insights we have on how to avoid written certification denials or maybe even a finer point is when you know there's a failure in your primary way of doing that, things that in our experience has been helpful as we've worked with clients through internal investigations and other appeals. What has been other helpful documentation that we've looked to, to primarily support the prognosis, the statement language of the certification requirement? And so these issues, I think for us have come up oftentimes in the context of earmarks or and a lot on how humans may use those those procedures to document different elements.

00:01:24:05 - 00:02:17:04
Andrew Brenton
Yeah, that's right. You know, whether it be sort of something within the how the MRO was configured or how, you know, hospice staff sort of used the EMR, you know, oftentimes we see in our investigations, just like you said, problems with certification documentation where, you know, one of the many Medicare certification requirements is missing or otherwise kind of facially deficient. So one of the things we do then is try to look and see elsewhere in the record if another document, you know, supports the certification standards. And just like you said, I think the most important content element that we would try to look for in that case would would be the prognosis statement.

00:02:18:00 - 00:03:01:04
Meg Pekarske
Which when we say prognosis statement, we mean the six month prognosis language. And so and I think as we've worked with clients, we have found that many do build in these redundancies. So the first thing we oftentimes look at is narratives, because as a matter of course, many physicians actually say, right, because the narrative is saying why this person is terminally ill, they'll start out their narrative or ended with this person has a six month prognosis or are less well because as you know, of X, Y, Z, and that that's been really helpful.

00:03:01:17 - 00:03:11:00
Andrew Brenton
Yep. Yeah, that has been been very helpful in some of our investigations. As kind of having that redundant prognosis statement. Absolutely.

00:03:11:14 - 00:04:38:12
Meg Pekarske
It could be useful for folks to work with their physicians and train them like this is the question you're asked, answering when you're writing a narrative. So start with that and it gives you the right frame of mind. Or even if you have your narrative form right. Everyone has form for their narrative and oftentimes it will have a description that says, you know, a brief narrative like this is a brief narrative as to why the person has a six month prognosis or less. And if you have that language above it, you know, and they signed it, you know, that's another way to sort of get at that because that's a natural document where it's no one writes a narrative. They don't think they're terminally ill. So I think the mere act of doing that is evidence of of that. But obviously making that that prognosis language a little bit more clear. The next thing we look at oftentimes is plans of care, because fall certifications aren't necessarily in order. I do think in our experience, is working with a lot of different clients that it does get plugged in sometimes as an order with other orders on the plan of care. And so if there is a prognosis statement there, that can be helpful.

00:04:39:06 - 00:05:42:08
Andrew Brenton
Yeah. Yeah, absolutely. And, you know, if the hospice is creating or updating the plan of care, I mean, clearly the physician in that case would have considered the patient to be terminally ill. So including that six month or less kind of full prognosis statement would seem to make sense there. And if you kind of go down that route of trying to build in some redundancy within the plan of care, a couple of things to kind of keep in mind. You know, if you did want to use that document as redundant, certification down the road, if you were kind of forced into that position, you know, the physician, you would want the physician to sign that document. Also, the timing of the you know, when the physician would sign the planet care. You know, that could impact kind of how we would use that because of course, there are timing requirements related to the certification and whether the physician sign the planet care kind of within those timeframes would be something that we'd have to look at to. But yeah.

00:05:43:01 - 00:06:56:18
Meg Pekarske
There are so many complications with these and that's why these redundancies aren't foolproof, but because they then you need to look at all these other elements, as you say, to these certifications, which there are so many identity crossing things to this. But it can be very, very helpful And I think another place we look is face to face visit now. Now, many hospices use primarily nurse practitioners to do that. But if you are having hospice physicians do that now, if they're the certifying physician they may not do a full visit node. But, you know, if they are, you know, also building and that like this person has a six month prognosis or appears to have a six month prognosis, you know, as evidenced by, you know, these types of things because that node is really assessing them about, you know, do they continue to demonstrate that limited life expectancy. So that's another place that has been helpful for us.

00:06:57:09 - 00:07:34:01
Andrew Brenton
Yup. Yup. Absolutely. And kind of getting at that complexity we were talking about, of course, the Face-To-Face visit can be completed up to 30 days before the benefit period, whereas the certification itself can be completed up to only 15 days. So again, just another kind of layer on top of all of this. But if you were to try to use that face to face visit, not as are done in certification, the dates would have to line up such that, you know, it would be time we from a certification perspective.

00:07:34:05 - 00:09:59:23
Meg Pekarske
A couple other places that I think are more one off and and I don't know that I would put them on my short list but you know, some people similar to the point of care have a physician order for it that's like a certification so that might be another place to to look and then the verbal certification Now it's very clear through guidance and I think while accepted that that verbal certification does not need to be signed And I think we always suggest the verbal certification should actually be spelled out like use the prognosis statement they're while not required we do see some people as a matter of practice have physicians sign off on that verbal certification. And so if that's something you do that's also a place you could look. If, again, human error led to your your primary way of documenting written certification, This could be another way to to prove that. I think, you know, I'm not a hospice operator, but I do think we're trying to cut down on how many things people have to sign. So for having people sign off on things that aren't necessarily require. That's why I think our short list started with things that physicians are already having to sign that are directly connected to their determination that someone has a six month prognosis. And so you know, this is sort of the quick hit, I think, as you hinted at. Andrew, there's a lot of complexity when we've had to dig into these issues. And so but I think we have found a lot of clients have done some great training with their physicians around What questions are you always answering and what is it that you're thinking about? And it's always about why does this person have a six month prognosis? And so spelling that out more times than than once can be can be helpful when again, your your primary system maybe falls short in an isolated instance or whatnot. But any closing thoughts? Andrew?

00:10:00:19 - 00:10:41:23
Andrew Brenton
Well, just that I think you're your last point about you know, balance is important. So, you know, it's great kind of building all these redundancies and that and the worst case scenario where you know, we have to defend something, whether from an appeal perspective or from just an internal investigation perspective. But, you know, that doesn't mean necessarily that you should kind of be completely revamping how you're kind of, you know, completing all these documents just so that you are kind of setting yourself up to, you know, in the worst case scenario, defend yourself. So it's kind of a balance things to consider, not necessarily just kind of slapdash, execute all at once.

00:10:42:03 - 00:11:57:09
Meg Pekarske
Well, and podcast that hasn't yet been released that we recorded earlier this week. It really talking about education fatigue and and like it was in the context of tpy and you know, throwing a bunch of changes at people all the time. Like we could do this better, we can do this better and it's sort of picking and choosing what makes sense and what's going to move the mark the most And I think this is similar to like just because you listened to this podcast and now I'm going to create five new systems or redundancies, but I hopefully there are some nuggets here that that might be helpful because as we're saying, all of these concepts we're talking about physicians are already doing an action that is, you know, indicative that they believe this person has a six month prognosis And so building in that language can be can be helpful when you're training them, and it keeps them focused on what matters. So well, thanks for for the insights, Andrew and I look forward to next time.

00:11:58:02 - 00:11:59:05
Andrew Brenton
Yeah, me too.

00:12:02:18 - 00:12:18:12
Meg Pekarske
Well, that's it for today's episode of Hospice Insights, The Law and Beyond. Thank you for joining the conversation. To subscribe to our podcast visit our website at or sign up wherever you get your podcasts. Till next time, may the wind be at your back.


Andrew Brenton

Senior Associate