This transcript has been auto generated
00;00;00;00 - 00;00;37;22
Meg Pekarske
Hello and welcome to Hospice Insights: The Law and Beyond where we connect you to what matters in the ever-changing world of hospice and palliative care. Election Inspection: Be Proactive to Avoid Costly Election Statement Denials. Oh my goodness Josi, Bryan, this is an important topic we're covering today because because these can be real money issues. And we've been, I think, ever since the 2020 changes up to the election form.
00;00;37;24 - 00;01;04;09
Meg Pekarske
We've been dealing with lots and lots and lots of election denials. And so, unfortunately, CMS has a battle form. But even sometimes when folks have used something very similar to the battle form, and it hasn't necessarily always been a reprieve though. So important topic. So thank you for for sharing your time and expertise today.
00;01;04;09 - 00;01;19;06
Meg Pekarske
So so tell me, Bryan, I mean, it may be obvious to everyone, but just to level set here, why do election statements matter so much and why it's such a important topic to get right.
00;01;19;09 - 00;01;46;14
Bryan Nowicki
Yeah, elections are probably the most important. Maybe not even probably the most important document requirement of the heart Medicare hospice benefit. And that goes for Medicaid too, because states are going to have similar requirements. It is the document where the patient says they want to be on the Medicare hospice benefit. They're waiving their right to, all other kinds of Medicare, coverage.
00;01;46;16 - 00;02;16;17
Bryan Nowicki
So they're really making that election to get into the hospice, which provides very specific kind of care. The hospice is becoming essentially the sole caregiver for that patient in many respects. And payment is tied. All hospice Medicare payments are tied to a valid election statement. So if you do not have a valid election statement, then every dollar you received for services you provided that patient is going to be forfeit or taken back.
00;02;16;19 - 00;02;35;03
Bryan Nowicki
And that's if the patient was on hospice for one day or one year or three years. So it really can add up. And once you have, invalid election, then you're serving a patient for two years and then you get audited and realize, oh, we had a bad election statement. It's not a whole lot. You can do about it.
00;02;35;09 - 00;02;40;23
Bryan Nowicki
So very important to get those elections into shape confidently at the outset.
00;02;40;25 - 00;03;05;28
Meg Pekarske
So I bristle at the word invalid because we're lawyers and I never see anything that's invalid. Because I think there's always and I think our track record has shown like, you know, there are lots of ways to win election issues, but who wants to wring their hands over, that. So I and I think the common denials let's put them in two camps.
00;03;05;28 - 00;03;42;06
Meg Pekarske
One, we have the human error element, which is didn't fill it out. Right. And then we have the forms issue, which is my forms wrong. Both are problematic. But obviously your form being, being channel legible is, is like could impact potentially everything you build. And so again, all is not lost here because we've had we have a giant spreadsheet of like every single variant of election denial we've seen and how we've weathered that.
00;03;42;06 - 00;03;59;00
Meg Pekarske
And I think so just because the government initially claims something's not right doesn't again, mean that that's, an open and shut case. So so, Josi, tell tell us some of the common reasons for denial that you've been seeing.
00;03;59;02 - 00;04;21;16
Josi Wergin
Yes. And it's interesting that you mentioned that there's kind of two buckets, the something wrong with your form and also the human element. Well, there's also ways that you can design your form to reduce the risk of the human error. So some of the reasons we commonly see are required information just doesn't appear on your form at all.
00;04;21;19 - 00;04;52;15
Josi Wergin
So sometimes that's information related to the bbcso. Sometimes it's a mention of cost sharing. Or it's even when the auditor alleges that the information that's required doesn't appear, even if it really is there. Sometimes we have reviewers or even ALJ is saying that the election statement was missing cost sharing information. But then when we look at the election statement, we see that there is discussion of how costs will be shared.
00;04;52;17 - 00;05;25;26
Josi Wergin
It just doesn't use the word cost sharing. So sometimes it's a matter of convincing the decision makers, during appeals that yes, the information is there, but sometimes they are being very, very literal with the regulations and saying, I want to see cost sharing. I want to see those words. I want to see the words virtually all care, so that that's another bucket where sometimes we just want to give them what they want to see in the first place, so that we can reduce having to get into it with the regulators.
00;05;25;26 - 00;05;27;25
Josi Wergin
As you mentioned before, big.
00;05;27;28 - 00;06;16;17
Meg Pekarske
Yeah. And and I think sometimes unfortunately, this can be a moving target because we've had contractors approve things and later they look at the same form and say it's not right. So you know, it's a little head scratching and but but I do think there's a lot you can do to hopefully, eliminate that risk. And I think something that stands out for me, and I've been saying this for a long time, is often times, when people who the, the staff members that they have sometimes doing the election form may not be very well versed in the importance of this form.
00;06;16;20 - 00;06;47;01
Meg Pekarske
Or they might not maybe have the skill level, might not be there because it's just like, oh, this is paperwork. It doesn't matter. I just sign it. Right? And then it's if people don't really understand the implications of doing this. So, so when I just sign my mom into hospice, you know, the gold standard I think is really when you have the admission nurse did all the paperwork with us, and then they're able to explain things clinically.
00;06;47;01 - 00;07;20;01
Meg Pekarske
But I also think they're pretty astute at understanding that form and all these different things. And so that's different. I know sometimes people use business development folks to do that. You know, we're not saying that they can't, you know, do the same job. But I mean, I think when we talk about how to do these things, thinking about the who is doing it, and then also do they understand the importance of doing this right, because it's not really paperwork.
00;07;20;01 - 00;07;45;12
Meg Pekarske
People, want to get, including the patient to the meat of the matter. Like whatever. They're they're usually in some type of crisis when you're getting on to hospice and it's like, whatever, I'll sign whatever is needed. And so making sure, you know that you have a nurse or whoever you're choosing to that can be both compassionate, but then making sure they're doing that.
00;07;45;12 - 00;07;53;29
Meg Pekarske
I added crossing dating, you know, all the things that need to be done. But but tell me some other examples that you have there.
00;07;54;01 - 00;08;20;08
Josi Wergin
Yes. And and what you were just saying plays right into this. There are issues where we can have some human error creep in. So there may be a blank line for required information such as the effective date, but it's not filled in. And let me tell you that one breaks my heart when I see an effective date missing from an election statement, because a lot of times it's very clear from the rest of the documentation what the effective date is.
00;08;20;11 - 00;08;42;09
Josi Wergin
It just wasn't written down. And like you say, some it may be who's doing it. It may be that it just might be something that's missed because people are busy. They may be trying to comfort a family member who's really in a bad situation. You know, they're they're really hurting and they're trying to be compassionate, like you said in the moment.
00;08;42;09 - 00;09;06;07
Josi Wergin
And that even if they understand how important it is, that effective line gets left blank. Or you may have aspects of the election statement that can cause ambiguity or confusion again, if something is missing or not quite filled out. Right. So an example is some people have check boxes for choosing an attending physician. There might be a yes or no.
00;09;06;09 - 00;09;28;14
Josi Wergin
I want to choose. I do wish to choose an attending physician, and I do not wish to choose an attending physician. Sometimes we see people checking. I do not wish to choose an attending physician, but then they write the name of a physician on the blank line. So and we have people checking both boxes. They both do and do not want to choose an attending physician.
00;09;28;16 - 00;09;56;19
Josi Wergin
So it really can complicate things. But one way that you can really help out your staff and, you know, patients and their representatives is to, again, design the form to make it easy to do the right thing and difficult to do the wrong thing. So you can do things to minimize these sort of check box situations and minimize, a blank line being a super mega problem.
00;09;56;22 - 00;10;17;09
Josi Wergin
So for example, with the effective date, instead of having a blank line for the effective date, that always has to be filled in no matter what you could say, the effective date of the selection statement is identified on the following line. If that line is left blank, the effective date is the date on which the election statement is signed by me or my representative.
00;10;17;11 - 00;10;29;26
Josi Wergin
So that way, if the election statement is different from the date of signature, you can write that down. But if it's accidentally left blank, everybody understands that it is the date signed, which is usually the situation.
00;10;29;29 - 00;10;56;16
Meg Pekarske
Yep. I think that whole how you design the form, I mean I've looked at countless election forms over the years and it just is like people have people initially like template aces and all these checkboxes and you're like, how is anyone going to fill this in because you're having things initialed that don't need to be initialed, you're having multiple places to sign, you're having.
00;10;56;18 - 00;11;31;03
Meg Pekarske
And so it just I think all of it came with good intent. But, it it ends it increases the chances for for user error. But I think something that came about with the 2020 changes, to the election form, is really an opportunity to clear the decks a bit and look at your election form with new eyes, because it's frustrating looking at election forms, and you can see how they've just grown, like I've been in business for two years, I just keep adding stuff to it.
00;11;31;03 - 00;12;04;13
Meg Pekarske
So now it's like five page document that no one even knows why stuff is in there anymore. And it's like they put stuff in there that doesn't need to be in there. So then the nuts and bolts, which to your point, are things that the government saying can be problematic from a payment perspective, you know, get buried and lost and then completed incorrectly because there's too many places to initial check, too much information, too much.
00;12;04;13 - 00;12;25;15
Meg Pekarske
People are fatigued by read, I mean it just so I, the election form, that's the best came out with as real short. But what? So why don't you tell us a little bit about the US election form, both the good and bad, with that form, right.
00;12;25;15 - 00;13;05;25
Josi Wergin
So as you mentioned, it is very short and sometimes adding information can actually be helpful. So what other information did you give the patient to explain their, you know, the coverage and everything like that. Sometimes we go and look at those documents if we need to shore up some of our other arguments. So sometimes having a list of other things that you gave to the patient and discuss with the patient can be helpful if we if if the auditor finds some other problem with the election statement, then we need to talk about, how very well informed the patient actually was and their representative.
00;13;05;27 - 00;13;34;15
Josi Wergin
The other thing is that we have actually seen reviewers, and ALJ is denied the very language that is on the elections table in itself. So there's it's not a guarantee. There are definitely parts of that election statement that I will copy and paste whenever I'm helping somebody review their election statement. You know that there's some good information in there about the cost sharing that uses the words cost sharing.
00;13;34;18 - 00;13;46;01
Josi Wergin
So there's definitely things that are good. But they're pitfalls as well. And some of them are the same kinds of pitfalls that we were talking about earlier, like with checkboxes and blank lines and things like that.
00;13;46;03 - 00;14;17;18
Meg Pekarske
So, Bryan, you've been before many, many algaes, when we got a slew of election denials with like a zillion different variants, with the virtually all language, the sort of 2020 changes that we've been alluding to. Tell me, tell me what you glean from arguing these cases in front of ALJ, because these are very technical things that are like nonsense, like, this is stupid kind of stuff.
00;14;17;18 - 00;14;26;00
Meg Pekarske
Tell me, how do you argue? But there's something more that just this is stupid, judge. Tell me, tell me how this goes.
00;14;26;03 - 00;14;50;03
Bryan Nowicki
Yeah. And this kind of relates to what you alluded to earlier, Megan. That is, when you get those denials from the initial order, take it with a grain of salt because there are ways to overcome those. And when we get to the ALJ and I've argued, you know, dozens and dozens of these election cases, rail JS, for the most part, I think ALJ is once something one a practical solution.
00;14;50;05 - 00;15;14;13
Bryan Nowicki
We can make an argument that we complied with the law. But if you can also show this just makes practical sense. And the way the reviewers looked at it was really hyper technical in a way that made it unworkable or made it more difficult for people to access the hospice benefit, or was really an unfair financial consequence to the hospice.
00;15;14;16 - 00;15;37;28
Bryan Nowicki
Most ALJ are receptive to that. There. We do. I think I have encountered the ALJ. Who is that Josi talked to talked about, you know, we followed the exact language of the model and they just said, well, but the model is not the law. The regulation is the law. That's thankfully not the approach of most ALJ. So when you get to a hearing, you'll make make your argument about the language of the regulation.
00;15;37;28 - 00;16;00;11
Bryan Nowicki
But I would suggest also pointing out nobody's cheating anybody here. This was this is a practical solution. We have all the documents to show that this was the effect of date, to show that we gave this patient and their family not just the election, but an admission handbook and a set of policies and procedures that were incorporated into the election.
00;16;00;13 - 00;16;19;24
Bryan Nowicki
And so there's just a wealth of material, and you can't really say we we didn't that we were misleading the patient some way. It gets the ALJ comfortable with what the hospice is doing even outside of following the model election. And that's been, I think, a real important piece to our success in the various.
00;16;19;26 - 00;17;07;13
Meg Pekarske
So as we wrap up here, you know, we've touched on some of these things as we've we've worked through the these different issues. But what should people do. What are some takeaways? I mean, the first thing I think of is it's the what rock are you living that like you gotta stay, you know, connected with whether that status association, national association or you're just constantly looking for new regulation and changes because this is an ever changing the pace of regulatory change in our area of hospice is is I mean, it's night and day.
00;17;07;18 - 00;17;25;08
Meg Pekarske
I mean, I feel like every single, year has brought pretty significant changes. And so staying abreast of those things and then understanding how you're going to operationalize these things, but what are some other things folks should do? Josi.
00;17;25;11 - 00;17;47;03
Josi Wergin
So, Ruby, your election statements routinely or, you know, you can involve us to help review them, even if you know you've already got the changes from 2020, it's still a good idea to break those out and dust them off and look at your audit results. Don't necessarily assume that, oh, we left that line blank and we got a denial.
00;17;47;03 - 00;18;16;21
Josi Wergin
Well, we'll just remember to do it next time. It's still a good opportunity to think creatively and say, well, how could we actually design our form to be better? Make sure all the required elements are included. As stated in the regulations. Reducing checkboxes and blank lines can be helpful. As we discussed, and building and redundancy. So if you've got those other documents where you do discuss things with patients, you can cross-reference that on your election statement.
00;18;16;24 - 00;18;53;12
Josi Wergin
And then, you know, make sure those handouts you're saving, copies of the handouts that you give to patients, save copies of your patient handbook. You know, keep a note of when you change them and how they're changed. Just keep old versions so that you can provide what you provided to the patient at the time or their representative. Another thing is, if you are, you know, a lot of times we're moving toward electronic election statements, as with many other things, and we've seen denials related to stuff being missing when it's actually printed out, even if it's entered properly in the first place.
00;18;53;12 - 00;19;14;22
Josi Wergin
In the actual electronic system. But things just aren't printing out properly so early on, you know, when you go through reviews, do this as well. But when you switch to a new EMR, do some you your earliest election statements, print them out, see what they look like, make sure that electronic signatures have everything that the Macs want to see.
00;19;14;25 - 00;19;24;25
Josi Wergin
And then when you review them periodically, do the same thing. Just make sure everything is being captured, that you want to be captured and as required.
00;19;24;28 - 00;19;50;07
Meg Pekarske
Well, that's a really critical point. And so I think this should be part of your compliance plan. You know, audits. Now a word to the wise here though a couple of things. One is don't you should do these prevailing and you should do them near the real time. Right. So you should be auditing your election forms and how they're completed.
00;19;50;09 - 00;20;14;11
Meg Pekarske
But you don't want to wade to bondsmen to do that, right? So take a sample of like, elections that got signed the same day or next day or something. Because if there are problems, then hopefully you can, you know, address those. So I do think, as you said, doing your don't just wait for the government to audit your forms.
00;20;14;14 - 00;20;59;26
Meg Pekarske
You should be doing a pre-built audit on your election forms, but do a sample that's different than if you're looking at long length of stay patient is also a part of your compliance plan. You don't want to say, oh, they were admitted three years ago, I'll go audit their election form because that's just, you know, can lead to repayment, liability and other thing so that you want to be a little bit more strategic about that, but also to such a great point, Josi, you made, which is so many people just do their, you know, billing reviews by going into the medical record electronically, as opposed to printing it out as it would appear to the
00;20;59;26 - 00;21;34;26
Meg Pekarske
government auditor. And those things can look really different. And so I think that that make sure when you're doing your pre billing review, you're not just reviewing everything electronically, but and it sounds stupid to say this, but there are so many beyond just election issues, things that are not as they appear electronically. When you go to print them out or you don't know what print like view you have, and so you send the print view, that's not good and whatever.
00;21;34;26 - 00;21;59;00
Meg Pekarske
So so we should not wait for the government to evaluate us. We want to do, you know, prevailing reviews of this. Because that can get at the human error element. But as you say, fresh eyes on your own election forms and how how good or bad they are. And I think having legal counsel can give you some peace of mind doing that.
00;21;59;00 - 00;22;22;01
Meg Pekarske
But anyway, while this is a heartburn kind of situation when these happen, but, as with many things, it's not our first rodeo. So we've been around the block on this. I think I was mixing metaphors from the block and that the rodeo was going around the block. But anyway, so, Bryan, I'm going to give you the last word.
00;22;22;01 - 00;22;24;22
Meg Pekarske
It's like two words.
00;22;24;24 - 00;22;52;26
Bryan Nowicki
Well, the reason we're doing this podcast is because a number of hospices have come to us asking us to kind of do a checkup for them. And I'm always happy they do that because I just feel with Josi, in reviewing these, we are preempting a lot of problems. We've always been able to provide, I think, some really useful feedback so that that annual checkup is really, worth worth the resource worth, worth the effort of going through that because you're going to save yourself
00;22;52;26 - 00;22;54;27
Bryan Nowicki
problems. No.
00;22;55;00 - 00;23;13;19
Meg Pekarske
Absolutely. Well, thanks as always. And Josi, you're just a gem. We're so glad that you're part of our team and you're just awesome. So thank you for helping us navigate all these issues. And, so until next time
Josi Wergin
Thank you.
00;23;13;21 - 00;23;33;27
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 huschblackwell.com or sign up wherever you get your podcasts. Until next time, may the wind be at your back.