This transcript has been auto generated
00;00;00;00 - 00;00;30;15
Bryan Nowicki
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. High Risk Hospices Are in the Hot Seat Across Six States. Hello, Zaina. How are you doing? Welcome to the podcast as I am beginning to host these in the absence of our leader Meg, who is now hopefully enjoying retirement.
00;00;30;16 - 00;00;30;28
Bryan Nowicki
Welcome.
00;00;30;29 - 00;00;40;21
Zaina Niles
Thank you, Bryan. It's it's been a while since I've been on a podcast, but I'm excited to be here with you today to talk about some new developments in the hospice space.
00;00;40;22 - 00;01;10;00
Bryan Nowicki
Great. Well, you know, we need all the we need to really come together as a team. Now we have a little bit of a different dynamic. Meg was so encompassing of the whole hospice field. It takes more than one person to try to replace what she offered. So I appreciate you being here to to be an important part of the team and to help us out. And what I wanted to, in particular, what I thought would be valuable given your experience and recent news is talk about the enhanced enforcement that CMS is
00;01;10;06 - 00;01;39;10
Bryan Nowicki
they began imposing a couple of years ago, but it just recently expanded. And there's a couple of flavors of that. One is the provisional period of enhanced enforcement that applies to new hospices. And that's, I think, gotten a lot of attention, maybe relatively more attention than the one you and I are going to talk about. The PPEO started in the four western states Arizona, California, Nevada, Texas, and then in December 2025 was expanded into Georgia and Ohio.
00;01;39;17 - 00;02;01;18
Bryan Nowicki
But that's the new hospice issue. And we're having, some podcasts on that, including the process of the PPEO and then a separate podcast on what does it mean to be a quote unquote, new hospice. But what you and I are going to talk about is kind of the parallel of that enhanced enforcement that is different from the PPEO in some important respects.
00;02;01;18 - 00;02;14;19
Bryan Nowicki
One of them is that it's not limited to new hospices. So, Zaina, why don't you kind of give us a little bit of history of your experience and working on, these expanded prepayment reviews?
00;02;14;20 - 00;02;51;10
Zaina Niles
Sure. Like you said, Bryan, these are sort of a sister audit to the PPEO reviews, whereas those deal with new providers, which is defined in the regulations, EPR or expanded prepayment review kind of covers all of the other hospices that exist within the industry. So anyone who doesn't meet that statutory or regulatory definition of a quote unquote new provider, and unlike PPEO, the events that can trigger this EPR expanded prepayment review are a little bit less defined.
00;02;51;13 - 00;03;19;01
Zaina Niles
We think based on our experience working with a number of hospices on this type of audit, that it's possibly related to other changes in PECOS. Things other than a 100% change in ownership, or even reviews of billing data that are going on behind the scenes, using a sort of black box algorithm that we are not privy to as provider representatives.
00;03;19;01 - 00;03;38;04
Bryan Nowicki
Yeah, I think we've we've had some clients come to us and, you know, everybody's wondering why you know why. Why me? How come I got pulled up into a EPR and a couple of them did something as seemingly well, it could be significant from a business perspective, but from an enrollment perspective, not all that significant, like a name change.
00;03;38;04 - 00;03;54;14
Bryan Nowicki
They're doing a new DBA, a new brand. And Zaina I remember working with you on this and trying to see, is that really the cause? I don't think we came up. We weren't satisfied that that was a cause and effect, a name change leading to an EPR, is that right?
00;03;54;16 - 00;04;33;27
Zaina Niles
Yeah. That's correct. It's it's still unknown. We've we've seen minor or sort of innocuous changes in PECOS like that in a couple of cases, but we haven't seen that in every single EPR case that we've worked on together. So it's not a 1 to 1. And we're still, you know, every day working across these audits that are each different, trying to distill themes, and figure out really what the reviewers are targeting here, besides just casting a wide net over existing providers in those the same six states that you mentioned are under PPEO right now.
00;04;33;27 - 00;04;58;05
Bryan Nowicki
And I think another observation we've made is that, at least from our perspective, the EPRs are more rare than the PPEO. So I would say for every EPR we've worked on, we probably worked on three or 4 or 5 PPEOs for whatever reason. So, again, what is triggering them? And are they going after big, small, medium hospices?
00;04;58;07 - 00;05;17;23
Bryan Nowicki
A lot of, uncertainty. But, you know, CMS, they don't need a defined reason to do any of this. We're often told by MACs or our clients report being told by MACs. We could review every claim, every time you submit one, if we want it to, but they don't. So that's not at all comforting. But, But yeah, they could they can do all of this.
00;05;17;23 - 00;05;26;03
Bryan Nowicki
So what is an EPR when, when, when somebody when we're talking about EPR, what does that really mean. What are we talking about?
00;05;26;03 - 00;05;48;26
Zaina Niles
So, expanded prepayment review is what NGS who is one of the MACs that conducts this type of audit. And that's what they refer to these audits as, Palmetto will refer to these as a targeted high risk review. So that gives us a little bit more insight into, you know, the cause of their algorithm behind the scenes.
00;05;49;02 - 00;06;19;08
Zaina Niles
They believe that these are high risk provider errors. But the process that we've observed and again, there's a lot of variation in how these audits are conducted. But generally what we've seen in the these EPR is are one round of ten claim review followed by a 100% prepayment review. And so you can imagine, Bryan, if you have ten 80 hours, you submit records, you get a decision letter with an error rate.
00;06;19;08 - 00;06;45;12
Zaina Niles
And then all of a sudden you see all of your claims in DDE go into ADR status. That's going to be very alarming. And if they remain, kind of on that trajectory, that's hugely administratively burdensome for the hospice to respond to all of those ADRs, it's impacting cash flow as hospices are putting those ADR responses together and awaiting decisions.
00;06;45;15 - 00;06;58;10
Zaina Niles
So it's very, very consequential and pretty quickly, a very small number of claims reviewed that can result in a de facto payment suspension, for all intents and purposes.
00;06;58;10 - 00;07;30;26
Bryan Nowicki
Yeah, I think when we've seen them go into that 100% prepayment review, that could be 90 claims, 180 claims. I mean, it's how many claims you submit 100% means 100%. We've seen some pretty significant providers get hit with that. And so I think of, you know, rough roughly 100 claims at about 40, 800, 5000, a claim that's half million dollars that you're not going to get as soon as you typically would get it and may not get it until after an appeal process, depending upon how that review goes.
00;07;30;27 - 00;07;42;24
Bryan Nowicki
You know, you talked about, I think, an initial sample or they start out small. How small do they start and are? Is there any target that a hospice should keep in mind to try to avoid getting to that 100% prepayment review?
00;07;42;24 - 00;08;08;02
Zaina Niles
So typically the MAC will look at ten claims they'll issue ten ADRs. But we've also seen variability in that as well. We've seen, I think as low as 6 or 7 ADRs issued in a round one review. And what the hospice is shooting for there should be getting an error rate of 20% or less.
00;08;08;05 - 00;08;29;10
Zaina Niles
The MACs won't tell you that in the initiation letter that you receive or in the communications that you receive, but they will tell you if your error rate is above that threshold, such that you're going to be subjected to some of the more serious consequences that we mentioned up to, and including that 100% prepayment review.
00;08;29;12 - 00;08;43;00
Bryan Nowicki
So you get these ADRs for some claims. How does a hospice to know? Well, this is an EPR ADR as opposed to a TPE or just a regular run of the mill ADR? What's the signifying element of those?
00;08;43;02 - 00;09;08;14
Zaina Niles
That's a great question, Bryan. And this is something very important for compliance folks to keep in mind. You know, as you're in DDE, as you're pulling ADRs, you want to make sure that you are paying attention to whether this is a TPE versus a more consequential audit, like, an EPR. And so you should be able to see a reason code on the ADRs.
00;09;08;17 - 00;09;36;13
Zaina Niles
And those reason codes also differ based on the MAC. So now across the six states we have three in NGS jurisdictions and three in Palmetto jurisdictions. So if you're in one of those NGS states, the reason code you want to look for on your ADR is 5C6HA. And then if you're in a Palmetto jurisdiction, you want to look for 51HRH.
00;09;36;16 - 00;10;02;29
Zaina Niles
The language in the ADR themselves is pretty generic. Unlike a PPEO, you're not going to see the exact words in the the ADRs themselves letting you know it's an expanded prepayment review. So really the reason code is going to be the number one thing that you should look for. And then also generally speaking, we talked about the number of ADRs you can expect to receive.
00;10;03;01 - 00;10;15;13
Zaina Niles
If they come in in a batch of 7 to 10, maybe look a little more closely at those ADRs, whereas TPEs, they're going to be looking at anywhere from 20 to 40 claims.
00;10;15;19 - 00;10;37;27
Bryan Nowicki
So with with the TPE review, let's assume this is one that starts out with the sample. You're getting 7 to 10. The ADR means they're requesting your medical records for those. You have a certain amount of time to submit it. And I think the cadence is similar to, a typical ADR. You submit the records within a couple weeks, you might know, did you get paid or did you not get paid?
00;10;37;27 - 00;10;48;05
Bryan Nowicki
Maybe there's a denial. Did they do, review or, round one results letters. Is that a common and consistent thing that a hospice can expect with an EPR?
00;10;48;05 - 00;11;18;22
Zaina Niles
Yes. You should upon submission of all of the ADR responses and a decision issued by the MAC, you should get a physical letter that is titled Round One Review Results. Associated with the EPR. And it will give you a CMS claims error rate along with some, you know, pretty abbreviated reasons for why any of the denied claims were denied.
00;11;18;24 - 00;11;45;09
Zaina Niles
And that's what is going to, trigger your appeal deadline. It will give you some additional information about what you can expect to happen next. Unfortunately, it is pretty generic, so it doesn't often give hospices the type of insight that they're hoping for into why a claim was denied. But that's all we can expect and all we've received from the MACs in our experience so far.
00;11;45;09 - 00;11;53;12
Bryan Nowicki
What are some common denial reasons? Have we detected any areas of focus or when, the MACs are looking at EPR based claim?
00;11;53;12 - 00;12;17;02
Zaina Niles
Definitely. So the the denials we're seeing most often fall into two buckets. We have clinical denials and technical denials. Clinical denials. I'm sure a lot of our clients and listeners are familiar with that type of denial. So that's just an allegation that the medical records don't support a terminal prognosis of six months or less. And that might be the only information that you get from the MAC.
00;12;17;02 - 00;12;51;03
Zaina Niles
In the EPR context. You're not going to get a paragraph or narrative description of why the reviewer thinks clinical eligibility is not supported. They'll just tell you that they think clinical eligibility is not supported. The second bucket is technical denial. So anything related to a perceived issue in the medical record documentation and by far, Bryan, the most common technical denial that we've seen in these EPR audits are related to the hospice election statement.
00;12;51;06 - 00;13;26;10
Zaina Niles
Most often, identification of certain content elements that the reviewer perceives to be missing from the election statement, things like cost sharing information, the right to receive the addendum to the election statement, and then also the BFCC QIO contact information. Those are all things that the reviewers like to point to as quote unquote missing and a basis on which to invalidate an election and deny claims.
00;13;26;10 - 00;13;50;29
Bryan Nowicki
Yeah. And I think, particularly for the, providers, the hospices in Georgia and Ohio, that now you may get these EPAs and now's an opportune time to beef up or reinstitute or just, bring back online any kind of pre billing audit you have so that you could make sure your election statements are up to snuff on a pre billing basis.
00;13;50;29 - 00;14;10;14
Bryan Nowicki
So if you need to make any corrections or get a get a fresh election or try to do anything with the election, the certifications, the face to face, whatever it is that you do, that pre billing audit in case you do come under scrutiny of the EPR. That's also going to help if you're going to be under the PPO as well.
00;14;10;14 - 00;14;37;11
Bryan Nowicki
But to get those pre billing audits online because the scrutiny is going to be more intense if you're ever subjected to one of these with regard to like, you get an ADR based on, expanded prepayment review and you need to submit medical records. Is there any advocacy you could do at the outset to try to already make the argument that your medical records clearly support eligibility?
00;14;37;12 - 00;15;28;02
Zaina Niles
Definitely. As you know, Bryan, we often advocate against giving the reviewers more than what they ask for. And so I think in a quote unquote typical audit, we say give them the requested medical records and kind of leave it at that. In the EPR context, because of the potentially severe consequences of getting above that 20% error rate threshold, it is worth it to spend a little bit more time, on the front end to not only develop a very complete and organized medical record packet, but also to put together a sort of clinical summary document that pulls out key information from the medical records to be submitted that really highlights and supports the patient's clinical
00;15;28;02 - 00;16;01;00
Zaina Niles
eligibility for hospice services. And so that's that's really anything in the record that demonstrates stability or decline in cognitive, functional, nutritional status. Anything that supports that the patient meets the applicable local coverage determination guidelines and your jurisdiction and qualitative and quantitative information supporting the clinical judgment of the physician that certified the patient is terminally ill during the applicable period.
00;16;01;00 - 00;16;24;14
Bryan Nowicki
And we have tools. I know Zaina, you and I have worked over the years to develop some tools or templates that provide a way to organize clinical data in a persuasive summary, hitting upon all the topics you described. We have a short form. We have a long form. You know, whatever resources you have, you don't have a huge amount of resources in terms of physician time or personnel.
00;16;24;16 - 00;16;50;11
Bryan Nowicki
Even a short form could be helpful. And if you do have the resources, a much more comprehensive review, might be enough to get you out of an EPR as soon as possible. So you never have to deal with that 100% prepayment review. Well, what if you get these bad decisions? Well, you get decisions that say you don't have your medical records aren't good enough to support the terminal prognosis.
00;16;50;13 - 00;16;51;04
Bryan Nowicki
What do you do?
00;16;51;04 - 00;17;20;19
Zaina Niles
Well, one of the benefits of putting together that initial clinical summary to include with your EDR responses is that that document can be easily flipped and turned into a first round appeal. So you'll take the denial language from the reviewer, perhaps insert a rebuttal to directly address anything that they've commented on, because you should get more details about why the claim was denied at subsequent levels of appeal.
00;17;20;21 - 00;17;32;04
Zaina Niles
And then flip that into a very fast appeal to keep the process rolling and try to get those denials overturned sooner rather than later.
00;17;32;05 - 00;17;53;16
Bryan Nowicki
Yeah. And your first appeal goes right back to the people who did the initial decision. So it's you really want to get through the appeal process. So being quick with those. What if you get to the 100% review and instead of just seven claims, now they're reviewing 70 or 170 and you're getting denied, you get 90 denials or 130.
00;17;53;16 - 00;17;54;13
Bryan Nowicki
What do you do there?
00;17;54;14 - 00;18;27;24
Zaina Niles
Yeah, that's a really tough spot to be in. And we hope that you all who are listening don't don't get to that point, but you should turn around and appeal any denials very quickly, not just to try to get the money for those discrete claims, but also because that's how you get claimed and also return. That's a favorable fact that we can take to CMS or the MAC to show that the initial error rate was incorrect or unsupported.
00;18;27;26 - 00;18;53;02
Zaina Niles
So similar to the TPE context, where favorable appeal results are supposed to be taken into consideration, before you proceed to the next round, we want to kind of take advantage of that similar advocacy opportunity here and these more consequential prepay audits. So going back to CMS to say, hey, I had a 60% error rate initially.
00;18;53;02 - 00;19;20;20
Zaina Niles
What I was able to get four of those six denials overturned through the administrative appeals process. That's very, very persuasive. And that might be a reason that CMS or the MAC agrees to conduct a more limited round of review versus a 100% prepayment review. Or they could do some more creative things, like transition you into another type of audit.
00;19;20;23 - 00;19;23;04
Zaina Niles
And discontinuing the EPR.
00;19;23;05 - 00;19;38;28
Bryan Nowicki
Well, you're speaking very theoretical, but I'll, I think you ought to brag a bit, Zaina, because you've had success. And it's not just theory with you, but what kind of relief have you been able to help hospices obtain based upon some of the strategies you just described?
00;19;38;28 - 00;20;18;03
Zaina Niles
So in a couple of the cases, that come to mind immediately, more recent cases we were able to convince CMS and in that case, NGS to discontinue the 100% prepayment review and instead conduct a round two review of just ten claims. And in one of those cases, the MAC, we were happy with the outcome of the round two review in that the hospice was able to get below the error rate threshold in that second round, such that they were removed entirely from the EPR.
00;20;18;03 - 00;20;42;11
Zaina Niles
So that was a great result. There. And another case that comes to mind, very similarly, we were able to convince MAC, the MAC and CMS, hey, let's do a more limited round of review in round two. We weren't able to get below that 20% error rate threshold in round two, but we still were able to go back to the MAC later on and say, hey, look at all of these
00;20;42;14 - 00;21;17;24
Zaina Niles
round one and round two denials that we were able to get overturned through the administrative appeals process. And because of that appeal success, the MAC transitioned that hospice into a TPE review. And so that hospice is still under scrutiny. But as you can imagine a TPE is probably causing a lot less heartburn and a lot less upset administratively and financially than an EPR, its potential consequences, or the prior 100% prepay review.
00;21;17;25 - 00;21;48;02
Bryan Nowicki
Yeah. With these EPRs the consequence is immediate and very draconian. And beyond the 100% prepayment review, CMS has the discretion to take that to a revocation if they choose to do so. So while I don't think a TPE is any, you know, as any great thing where if you look at the alternative, you know, a TPE is in a much, puts the hospice in a much better position than an EPR because a TPE typically plays out over months.
00;21;48;02 - 00;22;16;15
Bryan Nowicki
It's 20 to 40 claims. And as we've talked about internally and we've had podcasts about TPEs, there's additional advocacy opportunities with that. So so yeah, I think I think those are some great successes. You've been able to achieve Zaina on the EPR front. So any any kind of parting words to our listeners out there who are concerned about or maybe they've gotten a notice or an ADR that's related to an EPR.
00;22;16;15 - 00;22;47;10
Zaina Niles
Yeah, just a reminder to look for those reason codes, advocate for clinical eligibility early versus waiting until you start getting claim denials. And then, of course, you know, Husch Blackwell has a lot of experience with these type of audits and the sister PPEOs. So we're always happy to serve as a resource. And like you mentioned, Bryan, we have a lot of tools that we've developed to try to prevent claim denials and then overcome claim denials, when they arrive.
00;22;47;11 - 00;23;11;23
Bryan Nowicki
Great. Well, thanks so much, Zaina. You made hosting a podcast very easy. So I appreciate that. And I'm sure we'll be talking, talking a lot, over the coming months and years about new events as they, as they arise. And hopefully it won't all be what hospices need to look out for now. Maybe we'll hopefully talk about what opportunities are out there to help them grow and and serve the patients who they care for so much.
00;23;11;23 - 00;23;38;13
Bryan Nowicki
So thanks again. Zaina. And I appreciate all the listeners out there. Take care. 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, take care.