This transcript has been auto generated
00;00;00;00 - 00;00;23;29
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. Hospice Audit Updates: UPICs May Pick You for a Prepayment Review. Welcome, Zaina, to another episode of our lovely podcast. How have you been?
00;00;24;00 - 00;00;26;04
Zaina Niles
Not bad. Thanks for having me again, Bryan.
00;00;26;08 - 00;00;52;19
Bryan Nowicki
Yeah, happy to do that. There's always a lot going on. I know in the hospice world, it seems, since I've started hosting this podcast, it's a lot of enforcement-based issues, but it's kind of out of necessity because we're seeing a lot of activity and new developments with government enforcement and audits, payments, suspensions, revocations, all that sort of stuff.
00;00;52;19 - 00;01;11;01
Bryan Nowicki
So, I think, Zaina, you and I, who, who, you know, you you in particular, who worked very deeply in this space, are kind of at the leading edge of this. We do our clients across the country kind of get first looks at the newest trends and what is emerging. And now we have this prepayment UPIC.
00;01;11;02 - 00;01;18;20
Bryan Nowicki
Why don't you describe what a prepayment UPIC is or and how it's different from what we've typically seen from the UPICs.
00;01;18;23 - 00;01;59;17
Zaina Niles
Sure. So a UPIC is a unified program integrity contractor. And historically the UPICs almost exclusively conducted post payment reviews. So they're sending record requests asking for documentation for dates of service that have already been paid. Recently, however, we have had a handful of clients come to us for assistance with prepayment UPICs. So this is definitely a new development here, and that means that the UPICs are reaching out and requesting records after claims have been billed, but before payment has ever been issued to those providers.
00;01;59;20 - 00;02;10;13
Bryan Nowicki
So we know UPICs the unified part of their name means they can do Medicare and/or Medicaid. And we've seen them do both. Is this a Medicare issue or is this a Medicaid issue?
00;02;10;14 - 00;02;37;08
Zaina Niles
This is mostly on the Medicare side, and we are seeing activity from all three of the UPICs. You know, we started off, getting several requests from from one among the group, and now we have seen all three contractors conduct this type of prepayment review. And just for our audience here, I'll list them out. We have Qlarant Integrity Solutions, SafeGuard Services, LLC.
00;02;37;10 - 00;02;41;04
Zaina Niles
And then last to the party here is CoventBridge.
00;02;41;06 - 00;03;06;14
Bryan Nowicki
Yeah. Each one covers a different region of the country. And I think when whenever you see one UPIC do something you always wonder, is that their innovation or is this a more kind of did it, did it come from higher up at CMS to implement something new? And now that all three, we have evidence of all three doing this, it sounds like some strategy that CMS has implemented
00;03;06;16 - 00;03;30;07
Bryan Nowicki
among the many strategies and efforts it has, has implemented over the past couple of years to just really increase the pressure on hospices. So, all right, so we know we're familiar with UPICs and we have been for years. But as you said, these prepayment reviews are different just because of that. They are prepayment. What else is what else is different about the prepayment
00;03;30;07 - 00;03;31;21
Bryan Nowicki
UPIC audits that we've seen.
00;03;31;21 - 00;04;14;18
Zaina Niles
That's a good question Bryan. So previously with the post pay UPIC, hospices would receive requests for anywhere from 25 to 75ish claims, submit documentation and then receive a decision as to most recently just a fraction of those claims. Whereas the other claims would be excluded or undecided in some way. Here in the prepayment context, some of these are be being conducted in rounds similar to like we would see in a targeted probe and educate audit, for example, clearance their approach and at least a couple of examples that come to mind.
00;04;14;20 - 00;04;49;06
Zaina Niles
Recently they would issue ten additional documentation requests. So asking records for records for ten patients, ten claims they will issue a decision as to all ten of those claims. And then just a little bit later, the hospice will receive another ten address, again seeking records for ten patients, ten claims. So it's more of a, round process at least, from what we're saying, safeguard has taken a slightly different approach.
00;04;49;06 - 00;05;12;13
Zaina Niles
They have been less inclined to, go to conduct the review on a round basis. Then client has. But like you mentioned, this is a different beast. A new type of audit. And all of the contractors, despite what we think might be a directive from CMS, is approaching this new type of audit just a little bit differently.
00;05;12;15 - 00;05;38;19
Bryan Nowicki
All right. So and CoventBridge, the newest one to the game I guess we're kind of waiting to see how they're going to approach this as well. So from what we've seen what are the results. I know, Zaina, our experience with Noridian-type audits, when those started a few years ago, it was pretty routine to get a 90 to 100% error rate.
00;05;38;25 - 00;05;52;27
Bryan Nowicki
That has come down a bit. So we can kind of see with other kinds of auditors. What kind of what's the range of an expected result? What have we seen with these prepayment UPICs in terms of the results that they as they've come in?
00;05;53;00 - 00;06;20;15
Zaina Niles
So from, the perspective of Qlarant and the audits that they're conducting, we have seen pretty high error rates, at least in round one. Whereas the hospices have fared better in round two. And we don't have a lot of insight into what's, making the difference in between round one and round two. I'd like to take credit and say that it is our, wonderful appeal documents that we're submitting, after round one.
00;06;20;17 - 00;06;53;29
Zaina Niles
But that is still somewhat of an unknown, SafeGuard has been a little bit more inclined to approve claims, but we have also seen some pretty high error rates in these SafeGuard prepayment UPIC audits. And one thing worth noting, Bryan, is, that this type of review is distinct from some of the other prepayment reviews that we regularly help hospices with, and that it doesn't have a defined error rate threshold, at least not one that we know of.
00;06;54;02 - 00;07;28;10
Zaina Niles
So unlike PPO, EPR, and TPE reviews, we don't exactly know what error rate we're shooting for. And so we don't yet have a great idea of whether or not a hospice will, in fact proceed to a round two based on their round one results. We have some indication that if you're falling around the 50% error rate range, after an initial round, you are most likely going to receive a second batch of adders and proceed into a round two.
00;07;28;15 - 00;07;31;23
Zaina Niles
But it's really unclear what that threshold or cutoff is.
00;07;31;23 - 00;07;39;13
Bryan Nowicki
And and what happens after round two. Do we know yet or where are we at with, what happens next in this process?
00;07;39;13 - 00;08;10;22
Zaina Niles
TBD so we might, we might have to regroup to do a follow up podcast on this episode once we have more information. But so far, we have not seen a lot of follow up actions. No. Very severe consequences, knock on wood. Following a round two review. But it it remains to be seen, even though we're not seeing any type of follow up audit yet, it's not outside the realm of possibility.
00;08;10;22 - 00;08;21;19
Zaina Niles
And at certain certainly would not be outside of the contractors discretion, to make a referral to another auditor. We just don't know yet.
00;08;21;20 - 00;08;41;00
Bryan Nowicki
Yeah. And we know UPICs have quite a bit of discretion and authority. UPICs are the ones who can do an extrapolation. They are the fraud investigators. So they work with other government enforcers to do those kinds of investigations. So they have a lot of authority, a lot of discretion. We haven't seen it play out.
00;08;41;00 - 00;09;01;04
Bryan Nowicki
And it seems like our clients have fared pretty well in trying to get error rates down, or at least trend in the right direction. So so that's good news. But yeah, the the rest of the story has yet to be told on what the bigger plan is with these prepayment UPICs. What else can you tell us about the prepayment UPICs.
00;09;01;04 - 00;09;20;25
Bryan Nowicki
Is there any other kind of aspect of them that is different from your typical, typical audit? I know in other cases, we've seen more coordinated action between contractors. Like a follow on TPE following, following a Noridian audit. What about in these UPICs? Have we seen something like that here? Sure.
00;09;20;25 - 00;09;51;19
Zaina Niles
So even though we don't yet have evidence of like a follow up TPE, as you mentioned, we have seen some, communication between these. UPIC auditors and the BFCC QIOs. So for example, has submitted records in response to a UPIC ADR and then a little bit later they will receive a records request from their BFCC QIO assigned to their region.
00;09;51;21 - 00;10;19;25
Zaina Niles
So those are focused on quality care concerns. It's a different type of review with the different appeal process, and it moves very quickly. But just know that if you are undergoing one of these prepayment, you pick audits. It's not outside the realm of possibility that you might hear from your BFCC QIO, in relation to something that the UPIC saw in the records and flagged to that separate entity for follow up.
00;10;19;27 - 00;10;41;16
Bryan Nowicki
Okay. So, so, let's say a, asterisk gets a notice from a UPIC and it's prepayment. And I think, you know, the default is they can expect maybe a round of ten or 10 to 20 claims, something like that. Well, what approach should they take in producing records and when once they get the results, how should they navigate that?
00;10;41;17 - 00;11;23;06
Zaina Niles
So similar to any other type of audit, the first thing you want to do is make sure that you are producing responsive, complete and organized medical records. That's going to help paint the picture of terminally of these patients and also hopefully avoid, any, of the documents being overlooked or misinterpreted by the reviewer. Another thing that you might want to consider that clients should consider in the prepayment context is preparing a brief summary to put on the top of their ADR response, and that doesn't have to be anything elaborate or lengthy.
00;11;23;08 - 00;11;50;28
Zaina Niles
It can be a fairly brief document that just pulls out some key data points that really highlight why the patient is terminally ill, and why the hospice services provided during that period were reasonable and necessary. And this makes sense in the context of this new audit type. Bryan, because we don't yet know what the long-term implications of poor performance on a prepayment UPIC are.
00;11;51;00 - 00;12;18;12
Zaina Niles
So it's definitely worth it to try to frontload some advocacy here. Get ahead of any potential clinical eligibility denials by feeding the reviewer some key information. And then another, reason why that can give you a leg up is if any of those claims are denied, you can then flip that patient clinical summary and turn it into a redetermination request, to jump into the administrative appeals process with both feet.
00;12;18;13 - 00;12;42;27
Bryan Nowicki
Yeah, that's a similar approach that, to what we take with TPEs, where you really your interest is in getting out of the TPE as soon as possible and get a low error rate, as opposed to really planning for the appeal process itself to be where you do, you do all your winning or losing. So, I know we've developed some tools, depending upon who your MAC is, for these patients summaries.
00;12;42;29 - 00;13;04;01
Bryan Nowicki
So if you're encountering a prepay UPIC or a TPE for that matter, you know, feel free to give Zaina or me a call. We can, kind of talk you through the process. And what's specific or particular about your situation. Describe some of the tools we use or we offer to clients to, to help them with that front end advocacy.
00;13;04;01 - 00;13;14;26
Bryan Nowicki
So, Zaina, any final words of wisdom or guidance or, or hope out there in light of yet another, yet another twist on these enforcement efforts?
00;13;15;00 - 00;13;40;07
Zaina Niles
Yeah, I would just say, hang in there. There are a lot of really great hospices and folks who are very passionate about providing end of life care that are getting caught up in this very wide net being cast right now. And really great hospices are under scrutiny, just like the fraudsters out there. And so, we're all riding this wave together.
00;13;40;09 - 00;14;03;19
Zaina Niles
Bryan and I are here to provide our insights whenever we can. And we encourage you all to, to reach out, and take advantage of, of our capabilities. And the knowledge that we've gathered, from helping hospices through all different types of audits, including, those that are new and still remain somewhat unknown.
00;14;03;22 - 00;14;25;03
Bryan Nowicki
All right. Well, great. Zaina, thanks for sharing. The kind of a breaking news or the latest developments on the enforcement front. And thanks everybody for listening to the podcast. Check out our website. If you don't, if you're not already, signed up to or subscribed to the podcast, go ahead and subscribe to get. We got a lot of resources for you and, give us your feedback.
00;14;25;03 - 00;14;35;25
Bryan Nowicki
Happy to hear from you. And if you have any ideas for a podcast episode you want us to tackle, we'd be happy to do that. Otherwise, take care.
00;14;35;27 - 00;14;55;28
Bryan Nowicki
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.