Hi everyone, we'll get started in just a just a moment. If you wouldn't mind making sure that you're on mute, that would be very helpful. Thank you so much. You know, all we want to do is live our beautiful life and not complain. Can hear Mark Fox, Mark, make sure you're on mute. Okay, thanks. Thanks everyone. We'll get started again just one more one more minute and then we'll get started. And again, please, if you wouldn't mind. The session is being recorded so we'd appreciate it if you can stay on mute, unless there's an opportunity to ask questions during the session here so thank you very much. Okay, well, to reward those of you who are on time, we appreciate you being here today. Thanks so much for being with us for our first 2022 for HMDCs by HMDCs webinar, the first of our series. We appreciate it. I'm Bruce Hammond. I serve as HMDCB's executive director. And before I introduce today's speaker, I'd just like to take a moment to provide a few updates and reminders. I've said this a couple of times already, but I'll say it one more time is just the session is being recorded for folks who aren't able to be with us live today. So please, again, make sure that you remain on mute, unless you have a question later on in the session. So a couple of reminders really quickly before we get started. First, HMDCB's initial application cycle is currently underway. I know most of you are already certified. But if you know someone who isn't a hospice physician who isn't yet certified, but should be, please encourage them to visit HMDCB.org slash apply before March 22nd. They save $250 in late fees. The final deadline is April 26. So we encourage them to apply this year if they can. Our second reminder, we just had our first HMDCB coffee chat. There's a hospice Zoom webinar. We just had our first HMDCB coffee chat of the year, and we had a great turnout. It's a great opportunity for certificants to engage around topics important to them. So if you were there, we hope you had a great experience, and the remainder of those for the rest of the year are on the screen here, as well as the months, at least, of our upcoming webinars. We're working on finalizing the timing. And then we wanted to make sure that you were aware of an upcoming Hospice Physician Compliance Conference, which takes place on April 1st, put together by Weatherby Resources. That event takes place, again, April 1st. And HMDCB certificants and those who have applied for certification this year receive a 15% discount. So please email Gina if you're interested in receiving that. The last reminder, and the last thing I wanted to just make sure to mention is we really appreciate the sponsors who have chosen to support HMDCB's series this year. They include Kindred at Home. They are a gold sponsor this year, and Bluegrass Care Navigators, who is, once again, a silver sponsor. So for the second year in a row, both of these companies have sponsored, and we greatly appreciate their support, which helps to keep these events complimentary for everyone. So again, we really appreciate their support. If your company might be interested in helping support these events, please feel free to reach out to me, bhammond.hmdcb.org, and we'll help you out and get you set up. So now, without further ado, I'd like to introduce our speaker for today, and that is Lauren Templeton. Dr. Templeton is the medical director for Hendrick Hospice, a division of Hendrick Health in Abilene, Texas. And also, she serves as a physician consultant with Weatherby Resources as well. She became HMDCB certified in 2018. And if you've been involved in any of our coffee chats or other events, you know she's incredibly knowledgeable about hospice regulations and compliance issues. She now serves also as a member of the Regulatory Committee for NHPCO, assisting with advocacy for the Medicare Hospice Benefit. Today, she'll be sharing some stories with you to help you be better prepared to deal with regulatory and compliance issues you may face in your role. And I'm going to take a moment now to just turn it over to Lauren, and thank you all once again for being with us. I was just chatting or laughing with them about how everyone still gets, or I do, still get the Zoom fear that something is going to go incorrectly with sound and all of that. Something just did with me. I don't know if I attract that to my own self by talking about it so much and laughing. Thank you so much for inviting me, Bruce, and the remainder of the HMDCB. It's exciting to be here today. Today is, while a webinar, definitely designed to be interactive, so please feel free to include your questions in the chat and then raise your hand. I'll do my best to find them, but, you know, honestly, if it feels like right to go off of mute and ask a question, I'm happy to take it, or we'll wait until the end to discuss, so please, again, absolutely should be very interactive. What I don't want it to be is scary, so, you know, typically we have this slide of objectives. I call it objectives slash warnings, so what I want from everyone today, each of you will have a different goal, realizing it after you finish the hour, but I want everyone to walk away with insight, and so, you know, your insight might be, well, I could really, you know, use some more brush up on the regulations or be more, have a more sound basis in regulations. Your insight might be, I need to be an advocate for our peers in the Medicare hospice benefit. I want to take a more active role into advocating for these issues and changes, and then some of you, the insight might be, I need to go call our hospice and make sure that we're doing things differently pretty quickly, but what I want everyone to walk away with is to have this, a little more oomph behind why we're doing what we're doing, what some of the consequences might be to doing things poorly or just maybe not even poorly but not understanding exactly what's going on when it comes to the regulations and their implication in auditing and payment-related scrutiny. So as I go forward here, I'm going to present several different OIG or Office of Inspector General debriefings or briefings that gave us some insight into what is concerning as far as the Medicare hospice benefit, and these are more specific to the physicians, and so the first thing to talk about is why is there this emphasis on the hospice physician? What is all the hubbub about? So really and truly, a lot of it comes down to money, and financially, are we the best stewards as hospices across the country, the best stewards of the government spending? And so as there have been all these audits over the year and this emphasis on are we admitting patients at the appropriate time, or do we have these long length of stays, the transition has been from looking at the entirety to really honing in on the role of the hospice physician. So with the increasing cost to hospice, so we have been growing hand over fist over years now as far as what we're billing, which to me, that's something to be very proud of. We want to be billing more, that means we're using the Medicare hospice benefit more frequently, so that's incredible, something that's wonderful. So the concern is, are we doing that appropriately? Are we doing that for the right beneficiaries? And then ultimately, there's a very small set of hospices out there that are doing this fraudulently, truly with the intent to gain financial benefit without providing appropriate services to patients. And so I am going to talk a little bit to that small portion, which hopefully that doesn't apply to anybody on this webinar today. But I do also, I felt personally, in my role with Weatherby, that understanding how this can go awry made me feel more of an urgency to truly getting the A, B, C, D, all the way through to Z of the Medicare hospice benefit, not just to protect my hospice, but to protect myself as a physician. And so I think a lot of physicians have been grandfathered into their role. We have more and more people, and that's a wonderful thing, truly the pioneers of how we got to where we are, that's incredible. But outside of that section of pioneers of hospice physicians and hospice personnel, there is this group that has just done a great job of jumping in and helping before really knowing a lot of what's going on. And unfortunately, I think some of them haven't been invested in to get the right education. And that leads to some of these issues we've had in hospices in the past with maybe a long length of stay or doing things incorrectly. Again, this is speaking just about the hospice physician, because there's all different reasons as to why things might go awry. But I really think in the last couple of years, this emphasis on the doctors in auditing hasn't come with the same urgency. We have to get all of these doctors educated and supported and to see how things can go incorrectly, how things can go horribly to really get what their role is, how they can, again, protect their hospice and protect themselves. So again, not meant to be scary. Some of it is scary. It was scary to me. But the intent truly is to empower you in your role as the doctor to understand that there's a lot to this and a lot, you know, that goes on behind the scenes or puts you behind bars. So first, we're going to talk about a brief that came out some time ago. It's been six years about the Office of Inspector General referencing that hospices should improve, one, their election statements. And this is prior to the recent changes in the election of hospice or the election statement, but increasing the robustness of the certifications of terminal illness. So what they found is that even though the core eligibility requirement for the a patient to be admitted to the Medicare Hospice Benefit is that physician certification itself, is that the written certification of terminal illness was not actually supporting why that patient had a poor prognosis. And that was an overwhelming majority in this report that they looked at these brief narratives that were supposedly composed by physicians that were just lackluster, not supporting what was going on, maybe incomplete, maybe not signed, maybe not done at all. So very, very, very concerning finding. Given that we are that core to how a patient admits to hospice, we're the core of saying that their prognosis is less than six months, giving that certification of terminal illness and certifying that their prognosis is less than six months. So as we go to the next slide here, these are some examples. There are three different examples. That's why you see them separated out as such of actual claim denials based on the physician written certification of terminal illness brief narrative. So for those of you who aren't familiar with the concept of talking about claim denials. So this is in the aspect of we talk about the conditions of participation and then we talk about the conditions for coverage or conditions for payment. This is when we're looking at payment related scrutiny or that the auditing that we've unfortunately all probably been a part of now, whether that be TPE, ADR, those types of things where the auditing is is connected to payment. So not a surveyor, not the onsite surveyor talking about, let's say, frequency of visits or something to that nature. This is the actual payment related auditing. So when we talk about the payment related auditing, so you're submitting your clinical record to them for their review to see if they agree with payment. And so that payment period is when they talk about a claim denial is we bill in a month long period that 30 or 31 day category. So when it's a claims based denial. So, for example, you'll see here we're talking about how if this narrative didn't support that the patient was terminally ill, that would apply to the potentially integrity of that claim. So denying payment for 30 or 31 days. So these are examples of statements that with Weatherby, they have actually seen specific to the physician narrative. And so when I first started in hospice, I think as a fellow and then as I did it myself, that the narrative was a nuisance, that it was something that I didn't really understand the power and the weight behind it. That is very much not the case now. I very, very much believe that some of the power in reversing hospices not receiving payment for services that they provided lies within our narrative, which is actually pretty simple for us to change the course, change the narrative to be something very powerful that demonstrates that a patient's prognosis is less than six months. So in these claims based denials where maybe they were looking at, you know, 100 claims potentially or maybe just one at a time, depending on where you're at and what you're involved in, the actual quotes coming back saying things like the hospice narratives were very brief and did not contain clinical justification to support a life expectancy of six months or less. So then that means they denied those 31 days of payment. Or you see here the next quote from a claims denial saying the certification of terminal illness form submitted for review were invalid as the physician's narrative did not support a life expectancy of six months or less. So I think what I didn't understand is that I never wanted to hear this. So when I'm writing my my narratives now, I think of these references. I think of the fact that these, you know, when my hospice deserves to receive payment for 30 or 31 days for the month of October, November, or we're just concluded the month of February. And when I sit down to compose this narrative, you know, this power that I have in this very small task is great, very, very great way to that physician narrative, wait to support eligibility and payment, and then wait, as you see here, to for them to decline payment to the hospice. And so something when we talk about the power of regulations, I really when we get into this auditing perspective, and we're having to defend ourselves, it's indefensible, these types of statements that say it was generic contained, you know, very nonspecific language did not support a prognosis of less than six months. But when you look at the example that I'm going to give on the next slide, I think that empowerment that we have of understanding the regulations actually gives us the ability to defend ourself in something like this. So when they speak towards the physician narrative, and I want you to look at this highlighted section here, that it didn't the speaking to the narrative specifically, this is a more general context, but that the documentation did not support changes in clinical status, new onset of symptoms, measurable data confirming to decline or aggressive disease progression. Now, while I think everyone on here would agree that those are best practice and what you want to include your documentation, they're actually not a regulatory requirement. There's no actual specific verbiage that says what has to go in there. It's just that it has to support a prognosis of less than six months. So if you receive these claims based denials on information such as did not include a FAST-4 or FAST-4 was 7A, and you certified that patient for congestive heart failure, I want us as physicians to understand this is grounds for us to defend ourselves, because they are basing their determination not on a regulatory requirement. So truly understanding all the aspects behind the physician narrative is extremely important. So for this example itself, now, please look at that top quote. There was no certification present in documentation submitted for the dates billed. And since there was no certification dating back to that period starting at December 29th to 2017, as you look there at the bottom, that means that January 1st through January 31st were all declined in payment dates, just because we as a hospice and with insight from the physician, obviously, didn't substantiate payment, fulfill our technical duties as far as completing things that are required to bill and be paid for, for providing care with our physician narrative and signed certification of terminal illness. So here's another example of a claims denial. This one is specific to speaking to renal failure, which in the instance in this one, if you actually could read the entire thing, the patient wasn't admitted for renal failure. So this is an example of how an auditor might misapply a local coverage determination to your patient. And that's important to take into consideration. I want to highlight the area here about diagnosis codes. So there has been more of an emphasis about appropriate coding in hospice when it comes to what diagnoses should be listed in the plan of care, and then that is what's listed in the billing claim itself. And that's one, first and foremost, that that terminal diagnosis is the selection of the physician, we should be the one who guides why this patient is admitted to hospice, what contributes to their prognosis, but ultimately, the chief decision and what goes in there is the ICD-10 coding convention. And so we have been informed and through final rules and multiple disclosures from CMS that we should be coding all currently clinically relevant and impactful diagnoses for your patient, whether related or unrelated, right. So here we talk, you see that this claims denial says that while they didn't support the documentation of ESRD, the hospice didn't support it. One of the reasons they pulled that out is that the coding, the diagnosis coding that was billed was stage four, instead of end-stage renal disease, which I found very interesting. They talked about that the documentation didn't support secondary conditions such as pneumonia, stasis ulcers, pressure ulcers, and delirium, which doesn't seem specific to ESRD, right? That seems more specific to our general decline category, or that disease specific for Alzheimer's disease or neurologic disease, which again, very interesting how they seem to pick and choose how they apply what's going on. So ultimately stating that the documentation didn't support a patient terminal for these issues and declining payment for again, January 1 to January 31. And so when we truly understand the regulatory requirement to the certification of terminal illness, I think it empowers us to include information in that brief narrative that allows an auditor to see into the brain of the physician to say, yes, this is why they think that this patient is terminally ill. And I see that now, right? And it's also an opportunity for me, I look at it too, to summarize the last benefit period, something that should be done very briefly. Obviously, it's a brief narrative, but it's a way to say, over 60 days, this patient has had this in the broad spectrum. So it may have been even improvement. When we talk about that sawtooth pattern of decline, you may have admitted somebody on the bottom of the sawtooth on that disease trajectory, and you're audited on the top of the sawtooth. So actually, as a patient is improving, well, what does that look like in terms of January 1 to January 31, in the payment related auditing world? Well, that just looks like a patient that's getting better. And our documentation as far as the remainder of the interdisciplinary group is probably saying things like family is so amazed at how well their patient is doing, getting out of bed so frequently which may just be up for meals in reality. And so the narrative is an opportunity when we truly understand the regulatory requirement that we are charged with documenting in supporting a prognosis of less than six months, you can talk about the fact that while this may have been a period of brief change, this is expected in organ failure, this is expected with a congestive heart failure patient. And with this evidence of, you know, progressive intonation and loss of a mid arm circumference, and continued dyspnea with any exertion and ejection fraction of 10%, this patient remains with the terminal prognosis. So it's an incredible power that we have written, or the written ability here when we're composing our brief narrative. Okay. So along the lines of the brief physician narrative, and I'll say that everything in here in this PowerPoint is taken from with some adjustments, you know, to be compliant of privacy perspective is taken exactly as it is, it's not made up with the exception of the quote on this slide at the bottom. So that's my disclaimer here. But I did this to make a point. So in my auditing experience with Weatherby, I've been with them for several years now, looking at different hospice clinical records, whether that be in a bigger scope with the OIG, or, you know, small scope reviewing CTIs, for example, it's been quite eye opening one. But the thing that's overwhelming to me is the frequency with which we don't as a physician understand the regulatory requirements surrounding the written certification of terminal illness and copy and paste our brief narrative from documentation from somebody else. So when we understand the regulations behind this, we know that we are the ones who are supposed to be reviewing the clinical record and composing or evaluating the patient herself and composing that brief narrative, not somebody else. So I did this one to make a point here. So some of you may be aware, this has been in the news for the past couple of years, really kind of fizzled out here at the end of 2021, about a hospice here in Texas, where the owner of the hospice pleaded guilty when they were evaluated for fraud, fraud and abuse and all types of different issues that expand over different aspects, not just the Medicare hospice benefit. But one of the things specific to that was that, you know, what they were investigating and found was that the owner was actually more in charge of who got admitted, who was discharged than the physician was. And so one of the complaints that they made was that the face to faces that were documented as being completed, actually were not completed. They then discovered that they would change how patients were admitted into what hospice to avoid their cap, or reaching their cap. So lots of different scary things involved here. But the point I want to make is that what hit home for me, when I looked at this, and I wasn't personally involved in this, so a lot of this information is just taken from what's in public record, is that it as you see in the first line here, Mr. Harris, who pleaded guilty prior to trial, then testified against his former employees. So as physicians, when we don't understand the implications of what we're doing, and this gentleman probably was at the center of everything that went wrong here, whether it be, you know, adjusting care of patients, even so far as adjusting the amount of opioids they received because they were on service for too long or transitioning over to different hospice provider numbers in order to avoid a cap, all of which were when you read about them are just awful. When you look at that in perspective of physicians who are copying and pasting someone else's work, if this is the climate that we're in, that first line of Mr. Harris testified against his former employees when he probably was the one who, you know, was assuring them that this stuff was okay. That's me taking a leap there and wasn't there, but it's what it seemed like to me. You know, it's hard to defend yourself as a doctor if you're the one who's supposed to be composing this narrative. And in actuality, everything that's in there is what nurse John wrote previously. So when I'm, you know, conducting an audit with Weatherby and we have, you know, a summary of our findings, it's really heartbreaking for me to talk about how the written certification is copy and pasted from the assessment from this nurse on this date. So even though when we write or sign our certification of terminal illness, attesting, you know, certain things that we, it was us who composed it, and this is based of our review of the record or evaluation of patient, how do you defend this when you get into situations like this? Especially if you don't even know that this is what's going on in your hospice. One of the stories that Weatherby shares is similar to this in the DOJ or OIG investigation that they were in the room with another hospice physician and a representative from the DOJ. And the question to the doctor was very simple, you know, in reviewing his role in certifying patients as terminally ill. The simple question was, what is your username and password to your electronic medical record? And so the point they're trying to make there is that this physician signed off on these certifications, these brief narratives, but never evaluated the patients. There was no documentation of physician visits. And then ultimately, if they don't know how to enter into their electronic medical record, how did they review the medical record in order to compose that narrative? And so as we go on here in the regular auditing world, which is for the vast majority of us looking at just long length of stay or, you know, GIP for long length of stay, those types of things, there's this niche of things that get a little scarier for doctors that we really need to understand the weight of what we're doing and what we're signing and how important that is as far as the big picture. And unfortunately, there is a bigger picture of fraud and abuse in the hospice world. So one of the OIG reports that briefs that came out, Dr. Templeton, while you're taking a water break, let me just share a funny one for you. I don't know if it's funny, ha ha, but it's funny. One time I was asked to look at someone's documentation for their certifications that help out this group. And the doctor had written this, which is probably backwards on the camera. I don't know if it's the right direction. And then underneath they had the official statements of certified less than six months of life remaining, but they literally wrote no change. And that was the certification document. That was my favorite, terrible certification documentation I've ever seen. It's different when those things are printed out and you are reading them as the outside reviewer and you look at this and you're like, oh my goodness. So when something is copy and pasted in there, when the gender is incorrect of how, you're the male physician and there's a female nurse and you can tell that there's a difference there or like vital signs, when you're not, when you're not, you know, like vital signs when you're not seeing the patient. So why are there vital signs in your brief narrative unless you're saying that it comes from somebody else? I think as Tommy alluded to, when you're reading it on the outside, looking in, some of the stuff looks pretty bad. I've seen some that said patient doing great, we'll probably have to discharge them soon. So, I mean, that's sweet and candid and that's wonderful that your hospice is working so hard to get them better, but the implication of you writing that in your physician narrative statement is very powerful to the negative. So we always wanna be powerful to the positive and the good stuff. So one of the OIG briefs, and thank you, Tommy, for jumping in. If anyone else wants to jump in at any time, just please chime in. The next one coming out is talking about eligibility, which is long length of stay, appropriate certification of patients is always on the forefront. They have released that they intend to do this work product talking about hospice patients admitted and if they were hospitalized in the year prior to admission to hospice. And so they're implying, which of course we know nothing else about this. This is almost the extent of what you know is that they're gonna look at hospitalization in the year prior to admission to hospice, okay? That's expected to come out in 2023. Very, very interesting that this is where their focus is. I am presuming their assumption is that if you don't go to the hospital in the year before hospice, does that mean that you're not eligible and why should we be admitting these patients potentially? Which to me is just so ironic because the intent is to keep patients out of the hospital in every area of healthcare, not just the Medicare Hospice Benefit, right? There's this huge push to keep them at home across the country, right? But their emphasis here in their work product is essentially potentially penalizing those hospices that are admitting hospice beneficiaries that have not been hospitalized in the last year. And again, that's an assumption, but we do know that this is the work that they intend to look at over the next year. And it is expected to come out as a report to us in 2023. Does anyone have any questions about that work product? Okay, good, because like I said, that's about all I know. So I think it's interesting. I think the potential for it to be misinterpreted is very high and we'll just have to see how it plays out. All right, so the next OIG brief that was released was just released here, I think seven to 10 days ago. This is talking about Medicare payments to patients who were on hospice, but the payments that were for non-hospice providers over the last 10 years. So you have payments, the per diem to the hospice, and these are payments that occurred in addition to that, right? So they're very clear here that they didn't look at related and unrelated. It was not that specific, but that what they are interpreting from this is basically accounts for the fact that they didn't look at related and unrelated because it's so profound how much money was paid to non-hospice things while patients were on hospice care, right? So their intent behind the data brief is insight to potential inappropriate payments to non-hospice providers. Okay, so this is what they found. 50% of the 1.2 to 1.6 million hospice beneficiaries each year received non-hospice items and services during a hospice period of care, right? So if we look at this in terms of other things, like the very short median length of stay that we have. Yeah, of course we have these outliers and all of us have some long length of stay patients, but our median length of stay across the country, I think a lot of people are really struggling with this. I know in our hospice, I feel like I can't turn around before they're not on service any longer. So if you think about in terms of that, that 50% of those people received non-hospice or that Medicare paid for non-hospice things, it's very profound, especially in this emphasis of what Medicare maintains that since the beginning of the Medicare Hospice Benefit, that we should be providing virtually all care and that everything essentially should be presumed to be related unless the physician, their opinion and their documentation justifies why something would be unrelated. So there's lots of information in this brief. I thought it was very interesting to see things play out in the information that they found. Of course, as I said, they didn't account for errors in billing. They didn't account for related or unrelatedness. So none of this is completely accurate in the story it tells, which is obviously common to the OIG briefs that they're not completely accurate in the story that they tell. But the trend that this tells is very concerning. So when they broke down Part B billing, it's not that the patient had an attending of record that was their primary care physician who was not employed by the hospice and they were appropriately billing Part B services for physician visits. They don't dive into the specifics of that, but it's not just physician visits. There was a drastic increase in a 30% increase in billing to DME for these patients. So what does that look like? That it wouldn't be provided by the hospice, but then also okay to be billed to Medicare. I mean, that durable medical equipment, I mean, that's what we're talking about is a dependency of the patient. So it's hard to justify why a walker shouldn't be provided by the hospice if that is what is needed and they develop the plan of care for that patient. So some of that might be, maybe there's certain DME that's not what you're contractually providing for your patient, but regardless, then they shouldn't turn around and go get that from a DME provider and bill Medicare for it. So that's very interesting. There was a wonderful reduction in Part A payments, which I noticed that the OIG really didn't emphasize, but there's a decrease in hospitalizations if you generalize Part A, hemodialysis, those types of things that the non-hospice Part A decreased drastically over time. Some of that I hope is hospitalizations that are determined to be unrelated. I think that is a hard press to justify these days when we talk about virtually all care should be provided by the hospice. One of the other reductions is skilled nursing care, which is wonderful. I know that was a struggle for a lot of us in COVID, especially when they waived the three midnight rule to admit to skilled services. It seemed like all of my terminally ill patients then required IV fluids or all kinds of things that made them scalable. That was a frustration, but you see here very clearly that we, as hospice over 10 years, definitely have this role in decreasing Part A billable over time. Probably should be even less than this though when we get into the nitty gritty about that. Okay. Dr. Templeton? Yeah. There's a question in the chat that says, would these services not be billed within the per diem? Right, that's a great question. That is actually at the middle, the core of all of this. So DME is the best example for me to give because there's so much to the physician services portion. Part D isn't included in this, but the medication portion, but let's use DME. So yes, absolutely. When you are taking care of your patient and developing the plan of care based off of the comprehensive assessment of what your patient and family needs together, working in the interdisciplinary group together, yes, that is something that is why we get paid in bundled services as a per diem. Those items that you've worked with together, whether that's medications, oxygen, physician visits, those types of things, that's what's included in the per diem. Sorry, administrative physician visits. Let me clarify there. So it's really hard pressed to see a 30% increase in DME billing here because yes, that should be part of the per diem. And even if that's something that's not contractually, something that you provide in your hospice, it still should not be billed to Medicare, right? So when we talk about the per diem as far as the other types of aspects, it really drills down to what's related and unrelated, what's understood and what's going completely outside of the plan of care. So the NHPCO has a position on this. They've already released it. They were quoted in Modern Healthcare, if any of you guys read that, while, well, I'll just say their statement piece first is that this is not a hospice problem. This is a system problem that we don't know when people are doing these things. We have patients that get hospitalized all the time and we have no idea until they get back home 48 hours later. Or how do I know when they go and see their cardiologist if we don't know and they don't tell us and they're on for congestive heart failure and they see the specialist without contacting the hospice and having that contract first, how are we able to control that? Absolutely, there is some truth to that. I mean, just no doubt about it that there are these things that happen that we may be penalized for that we have no awareness of. I signed into a nursing home electronic orders to sign them yesterday. And saw CBC, CMP, vitamin D, TSH, lipid panel ordered on my hospice patient that I didn't order that, but it had already gone through and it's already probably on its way to Medicare. And so we're scrambling to try to say, wait a minute, that's not appropriate to be billed in going through all those things. But if I hadn't been paying attention and being quick to see the electronic order, how do I keep other people from not understanding the hospice benefit and doing things that aren't appropriate to our patients? I agree with that 100%, but when I look at all of how this breaks down, I worry that we do have a good portion of how this is going awry. Let's see, Stephen, you said, will the consultants be billing the patient's hospice? So this is really diving into the nitty gritty of this. So if you as the physician have determined that something is related or unrelated, let's start there. If it's unrelated, different story, let's work with related. If that patient tells you, I really wanna continue to see my cardiologist and you say, well, we're happy to provide your cardiac care. You don't need to continue to see him. And they say, no, I want to continue to see them. And they also don't want that physician to be their attending of record. I mean, you have choices here. You can say, I'll contract with them to let you continue to see them because that's wonderful for all of us. And you would be paying the fees for that physician, right? But then you also get to bill into Part A services potentially. So then we have this other aspect of, no, I don't see the relevance of that. We're not going to contract with them or help with that. And then yes, you could work with the patient that they can continue to see them, but they would have to pay cash, not use their Medicare hospice benefit in order to pay for that physician visit. So that's a great question. It's just that as we get into those specifics, it's very different for each individual circumstance. I see another one. Perhaps the nursing home dietician ordered the labs as part of the MDS and care plan meeting with patient and family without involving hospice attending on your example of nursing home bill. Absolutely, absolutely. Or maybe this was a recurring order that they get those labs drawn every year and in their electronic record, even though we specifically said, please cancel all standard lab draws. That's something that slipped through and happened. Yeah, absolutely, absolutely. But those examples happen all the time. They're not rare. And so the NHPCO position that we're being penalized potentially here for something that we don't know about. And the advocacy is that we should have some ability to know when these types of things are happening so that we can stop them or develop them into what they should be. So from a regulatory perspective, though, we should be aware of what's current. It's our responsibility to work with our patients and families to develop one, a comprehensive plan of care that addresses their needs, but then educate them on how this works. What does it truly mean when you talk about the cardiologist visit? What does it truly mean that you provide this type of wheelchair and not the other type of wheelchair? Do we educate on the fact that because we provide this wheelchair and you're choosing to get your own wheelchair, you need to make sure that you don't bill Medicare for this, for those services, because we're providing something else according to our contractual arrangement that would provide the need for the patient. Or I don't know that we're getting into this level of detail. It's impossible to get into that level of detail within 24 hours of a patient admitting to hospice. And so maybe some of this needs to be, we work through, you get a little bit of leeway for the first seven days. Obviously that would never happen. That would be too wonderful. But a lot of it is on our shoulders. We have a responsibility to educate. And then let's talk about medications. I mean, if you say that you're appropriately deprescribing, saying this patient's not indicated, how many of us have had patients that say, I don't care if you tell me the Plavix isn't indicated anymore, I'm still going to get it. And then they go to their cardiologist for a visit that's not approved. And they don't tell you because you just told them they can't have their Plavix. And then the cardiologist sends the Plavix to Part D. And you see how this continues to go. And oh, by the way, I fell on my Plavix. And they said, you can't do that. So go get this walker from this DME company down the road too. So that's that pie chart on the right. I just covered it in one visit with a physician that's all not approved. But if we're really working with them, not on a, oh, we can't do that, or, oh, we don't provide that, but more of a let's work together to see why this medication isn't appropriate for you. What else can we use? What can we substitute? Why this might get into an occurrence where you get billed for this later on down the road and you have to pay not your Medicare co-pay, but now the full billing for that entire visit or for the wheelchair and those types of things. So there is a lot of this that has to do with our education. And so having sound regulatory understanding of what that means, the determination of relatedness and unrelatedness, how that translates out into how you use a formulary or your DME contracts, but then also what the implication is to educating the patients and families is absolutely invaluable. And so this really all comes down to a great understanding of a comprehensive assessment and the determination of relatedness, in my opinion, and then lots and lots and lots of education. But of course the advocacy on the part of the NHPCO that some of this is just other people's errors that we are trying or hardest to keep from happening that are still happening is 100% valid. When I saw that quote about we need something that protects us as the hospice, I was like, yes, please. I mean, what else can we do is how I feel sometimes. But I'm not sure that the intent behind this brief is that hospices need protected more so than we are doing something incorrectly. So we just need to do, we need to work through those both avenues there. And for DME vendors usually drive the billing. Yep, I hear you say that. Yes, as Alan, it's a great, great mention. We should be aware of interpretations and expectations of the governing fiscal intermediary. It's just a responsibility to understand you're in a contractual arrangement with Palmetto, NGS, CGS. They're essentially the bank of the Medicare dollars. They're the ones who determine how they're gonna give it and get it back. So yeah, I mean, that's basically the point of this whole webinar. We have to have a sound understanding of the federal regulations and how that plays into our Medicare administrative contractors in order to protect ourselves. Okay, anyone else have anything to say about that out loud instead of just chat? The bar graph also needs to be interpreted in light of rising healthcare costs per person and increased number of elderly in pool. A better interpretation would evolve per DM spending. Yeah, Frank, I think that's a great statement. It's just that I think they manipulate their bar graphs to make things look as bad as they can look for the hospice justifying their need to look at us even more closely. So that will probably paint a better picture for the hospices themselves. Okay, I'm gonna spend some of the last minutes just briefly going over what some of these OIG audits actually look like, and then happy to take any questions about this. So those of you who have seen some of these come through, there's been, gosh, 13 or 14 provider-specific OIG audits, which means there are 13 or 14 different hospice entities that have been audited by the Office of Inspector General. Typically, these had to do with eligibility. So for example, with Mission Hospice, which is one of the audits that I was involved in last year, this was a audit of 100 hospice claims. When they sampled and looked at those claims over a two-year span of billing from the hospice, they said 66 claims, good job, to Mission Hospice, and then 34 claims that did not comply with the requirements. So for 33 of the 34, they talked about eligibility determination, and then they also referenced a level of care billing, and then they actually also discussed that the election to hospice care was not appropriate, whether that be from timing or some other reason. So essentially, the 33 out of 100, what they then said, they extrapolated that in just a loose, just for general terms, let's say, then they proceeded to say 33% of everything that that hospice billed for in that billing period, because that was a sample size, is now what they assume done incorrectly with inappropriate eligibility. And so that tallied up to $10.5 million that is unallowable for Medicare reimbursement for hospice services. So again, they took 100 claims. They said, you did great for 66. There's 34, one had a level of care, 33 that was for eligibility purposes. Then they said, okay, 33 out of 100, we're going to say that means 33 out of 100 of everything for two years is now needs repaid. Okay, you can imagine, I know there's all different sizes of hospices on the line right now, what this would mean for all of you, but 10.5 million for mission hospice. Okay, so their comment is, you know, that give us the money back. So now you have 60 days. Here's, we want to check for 10.5 million to your Medicare administrative contractor. You're using that 60 day rule, which of course, you know, that's not actually how it works. But the implication is that mission was doing something incorrectly and that they need to strengthen their policies and procedures to ensure that their services comply with Medicare requirements. So they did that. Mission, of course, then hires their own legal representation to say, we don't agree with this and, you know, in an attempt to defend themselves. So through that attorney, then I got involved with Weatherby. And of course this is all public now, this is all released into the public. When we evaluated the physicians with Weatherby, evaluated those, we actually only agreed with them seven times instead of the 34 that were questioned. And then in our participation with that, it was just mind blowing to me as to how they came to these conclusions, but I'll give you some specifics as far as that's concerned. So essentially then this draft report goes back to the OIG from the lawyer, from Mission Hospice, the legal firm, saying, we disagree with you on all these points. They then put it into this nice thing with this pretty light and dark blue with the OIG emblem and say, yeah, but we don't agree with your disagreement. And then that's it. That's where Mission Hospice stood at the end of this. Now, obviously it continues on. There are other things that they'll do going forward, but I think for me, it was just so powerful to look at the process and how much we can do, not saying necessarily specific that Mission was doing anything in particular incorrectly, but what weight we carry as a physician in our documentation and then in our ability to defend our hospices from further data issues. And so what do I mean by that? I mean that their reviewer would look at things based off of what appeared to be hindsight. So even though they're looking at this patient in terms of let's say one certification period, what have you, because they know that the patient didn't die at six months, they then would use that information and say, and oh yeah, they didn't die, so I'm right. But there's no, we don't get that. We don't have a crystal ball to say, oh, I can predict that I'm wrong. There's just, so that it was very frustrating to see those references. Of course, they didn't say that they did that, but you can see in the manner that they wrote in their auditing that they used it in their determination. They use things like if a patient was on hospice for a different diagnosis, they applied a different LCD. So the example I gave before that you saw all the end-stage renal disease documentation, that patient was admitted for congestive heart failure. So they also would do things like in that last quote there, the IMRC is that reviewer, the OIG physician reviewer. The patient was not eligible for hospice because his quote, speech was clear and he was able to make needs known. The loss of weight did not equate to inability to maintain sufficient fluid and calorie intake. There was no increasing visits to the ER, inpatient admissions or physician visits and the patient had no infections or cough. So the patient was admitted for Parkinson's and had been on service. And so it's just very concerning to me that this is what they used because the whole goal is to keep them out of the emergency room and other physician visits and hospitalizations. But that reviewer used that against the hospice while the patient was admitted to hospice services, which is just absolutely insane to me. It was very, it felt very good to write the statement. The very point of hospice care is to avoid additional hospitalizations and is undertaken in lieu of physician visits. The assertion with respect to the patient not having eligibility does not pass muster. I mean, this is just absolutely absurd. What I will say though, is that when I reviewed this documentation, I had to review it from a physician lens. I had to pick out things to say, oh yeah, I understand that that hypotension reflects to this. I understand that that cough means this because I gave the hospice the benefit of the doubt, the understanding of end of life care. And what was so evident to me is the requirement and need for hospices to be very clear without misinterpretation or leaving room for misinterpretation in the clinical record about why certain things lead to others. So coughing frequently at meals, as the physician, when you are told that, let's say an interdisciplinary group meeting, working with the IDG to understand that this is a sign and symptom of clinical aspiration. And so then your team is documenting towards aspiration. And then maybe in your narrative, you say signs and symptoms of aspiration with resulting weight loss of five pounds. So being very clear, it's not enough to just say patient lost five pounds this past benefit period. I think as a part of this auditing, it's just absolutely a requirement that we are very powerful in anything that we write for the documentation of eligible hospice patients. Okay, so that is the end of my presentation. I apologize for going right to the end of time, but as Bruce spoke to, we have this Hospice Physician Compliance Conference on April 1st. So in this all day specific to physicians, CME virtual conference, it will be talking about all of the regulations to help support us, to keep us out of these situations that I talked about today, going through how to write that robust narrative, what is the real regulatory requirement for the physician narrative and the written certification, looking at the role of the interdisciplinary group, diving into higher levels of care. And so that is an amazing opportunity for physicians that we're offering on April 1st. So would love for you all to attend. Please, I'm open for any questions. I'll start with some that are in the chat. Grace says, is the need to be extremely clear and connect the dots fairly explicitly because the auditors are not medically trained? Sorry for you to address this. I think you don't know necessarily with each audit. With the example of the OIG audit, they would not release the specific credentials from the hospice, I said hospice, I didn't mean to say that, physician that reviewed that documentation. And so we don't know who that was. That was a physician though. Now, in some of the audits that I've been involved in with Weatherby, and personally for me, it's a nurse. And sometimes I look at them and think, wow, you don't have hospice experience. And sometimes I think that they do. So it really depends on the audit that you're involved in. That is definitely very frustrating when it's someone who clearly doesn't get what's going on in the field and the expectations for the care that we provide. Alan, I see your hand raised. Do you wanna ask a question? Sure. Actually, a possible clarification for people that for those that are less familiar with audits and compliance, you've very well identified the two broad categories that denials take place. Many people overemphasize the clinical, and as you pointed out, there are a lot of aspects to improve. But the other thing for people on this call that may not be familiar is to pay attention to technical denials. And that comes up with, you didn't follow the rules, you didn't do these other things. And therefore, they don't care about the clinical because they can justify denial of claims. And then if it becomes systemic or systematic, whether it's under programs of probe and educate or other extrapolation, you then as a hospice become liable. And so understanding all the players involved, the nuances is important. And then the question I will put out there since Lauren wasn't on the last coffee chat, for the benefit of others, would you speak to how just because something may be denied, like if you don't have the right modifier or your fiscal intermediary interprets something, that is not for all hospice everywhere. So if you have operations in different locations, there may be differences you need to be aware of in practice. Yeah, absolutely. And I'll take an even step bigger. So the understanding, and I did mention this before, but the federal umbrella is one, and that's what's statutory. And then you come down to your banks or the Medicare administrative contractors, Palmetto, NGS, CGS. And so a good example of this is the pre-hospice physician visit. So that's for a patient who's going to elect the Medicare hospice benefit. It's a billable visit that's prior to the patient's admission to hospice, but all three MACs don't reimburse that the same, which is very interesting, even though that's very clearly stated as an acceptable billable visit. Or there might be more emphasis into one aspect or another as published by that Medicare administrative contractor. One very obvious thing is that they audit different things. So it's not necessarily that everyone is targeting neurologic diseases right now. I mean, there are all types of different audits that are happening at every time within your umbrella. So if you have some sites in Texas and then some sites in California and all of these different floating parts, yes, you are required to be specific to that area. And then of course, then you throw in your state that you're in, you have those state requirements as well. So it gets very confusing. Alan, I really appreciate you talking about those lines and being confusing. What I think is even more confusing crossing lines is what we do based off of our policies and procedures versus what is regulation. So I see a lot of people talk about things like the research visit by the nurse or the research presentation to the interdisciplinary group meeting, even talking about the interdisciplinary group meeting in and of itself. Those are not regulatory requirements. We've translated into those things. So we do a specific recertification visit for nurses because we may be doing a more thorough assessment of everything that's going on. And then we present that to our physician and the interdisciplinary group in determining eligibility. But in actuality, what you might find in your record is that then you're putting all your eggs into the one basket of the recertification visit. And if that visit was in December and you get audited in January, then you don't have all that robust documentation. So there are a lot of examples of what we do that you have to be aware of where does that come from? First, is it really a rule? Is it something we've done because we've done it a long time? Is it federal? Or is it from your Medicare administrative contractor? Yes, thank you so much. One of those examples I gave about the physician narrative earlier, it doesn't matter how well the IDG did in their documentation because there was no narrative. So if you didn't date it correctly, it didn't have the right benefit periods, dates on it, and you don't understand that that's a requirement, then the billing will be denied. Okay. All right, any other questions? Alan, anything else to say about that? I think that there was confusion and Bruce and Gina might comment or others that were on the call that there were misunderstandings on appropriate billing with modifiers, related, unrelated, and also how the process works going through the hospice for pass-through. And so that might be helpful clarification, whether there's time today and that's in the interest of anyone on today's call, but we did recommend your upcoming session if people need more details. I'm not on retainer either by HMDCB or Lauren or Weatherby. Yeah, I think that's probably beyond what we have time for, but in general, I'll tell you, your Medicare administrative contractors have great picture flow diagrams for all of that. So if you bill for, if you Google for physician services and then just type in GVGW and see what comes back for you. I know CGS, they have like green and blue and it's beautiful how it passes through everything. They integrate the role of the attending physician when they're a nurse practitioner, how you may bill for nurse practitioner visits in your hospice, if that nurse practitioner is the attending of record, but there are wonderful flow diagrams that each Medicare administrative contractor has. And so that is a great resource. And maybe I can get that to Bruce and see if we can get that distributed too. Okay. Dr. Templeton, there's a question in the chat about the compliance conference. Click to the bottom. They can buy the recording for 200 and still get the same amount. No, unfortunately the recording is offered is part of that. If you can't attend, obviously then you have the recording itself, but it doesn't change the way the finances are billed specifically. But there is a link to the website available here and you'll have this PowerPoint, or I believe Gina Wright is the PowerPoint or just the recording. Okay. And so you can get all the specifics of information about the conference. Dr. Templeton, thank you so much. Thanks for being with us and everybody who stuck around for the extra 10 minutes here. Thank you very much for sticking around and being with us today. Really appreciate it. Again, we have some upcoming events. This event that's on the screen here, but also some upcoming additional webinars and upcoming additional coffee chats. We look forward to seeing you then. And once again, thanks so much, Lauren. Thank you. Appreciate it. Appreciate everybody. Have a good one.

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