So we're going to go ahead and get started. My name is Gina Parisi and I serve as the executive director for the Hospice Medical Director Certification Board. And we really appreciate you all being here today. Today's session will focus on navigating hospice audits and will be taught by Dr. Lauren Templeton. And we were going to have Kiri Cooley join us today, but she isn't feeling well. So Dr. Templeton will lead us through today's session. And today's session will provide a high level overview of the content that Dr. Templeton plans to teach during Weatherby's Hospice Audit Survival Training. And I want to provide a little bio on Dr. Templeton. She has been a physician consultant with Weatherby Resources since 2017 and currently works for the Penning Group as a hospice physician working in quality and compliance. Dr. Templeton has been a physician since 2009 and a hospice and palliative medicine physician since 2012. And she earned her HMDC credential in 2018. So we really encourage you to attend Weatherby's Hospice Audit Survival Training if you'd like to expand on the content that we're going to talk about today. So you can use the QR code on the screen to go ahead and register for that course. There's also a discount code there that's available for all HMDCB certificates. And this course will take a deep dive into the most prevalent hospice audits and you'll learn a step-by-step process to plan to ensure a timely and comprehensive response to these audits. We have a couple other HMDCB upcoming community events. A coffee chat will take place on September 9th at 3 p.m. Central. And then we'll partner with AHPM on September 19th to host a webinar focused on buprenorphine in hospice care. That registration isn't open yet, but it will open soon and you can register for that on AHPM's website. And then HMDCB will host another webinar in October that will focus on mindfulness and spirituality within hospice care. And just a friendly reminder for anyone that their credential expires this year, you do have until October 31st to complete the renewal process. So you can visit hmdcb.org slash ccp to learn more about that. And before we get started, I just wanna thank our sponsors for this webinar series, Gentiva Hospice and Heartland Hospice generously support this webinar series so that we can provide it for free for our certificants. So huge thank you to them. And if you're interested in learning more about the work that they do, we encourage you to visit their website. So I'm gonna go ahead and stop sharing my screen right now and hand it over to Dr. Templeton. Dr. Templeton, thank you so much for being here with us today. We look forward to learning from you. Awesome. I'm excited to be here and talk a little bit about navigating hospice series that's coming up. Let's see, share. Okay, yeah. If you all could just relay in the chat, if the screen looks good with my PowerPoint presentation, that would be great. So navigating hospice audits is something that's near and dear to my heart, especially as I've worked in my career with Weatherby in terms of really helping support the hospices that are out there providing excellent care and really diving into the provision of hospice care. Meaning we see our patients, we do symptom management, we do higher levels of care, we're discharging patients that are not eligible. And so I think in my career, I've developed this passion because I actually want to help good hospices navigate the system because it is no longer a culture where hospices can say, particularly if they're above a certain size, that because they're a good hospice, they will not be audited. That is just no longer the case. And so as we go through today, I'm going to give you an overview as to why, why that's the truth, that hospices are going to be audited. A brief introduction into what types of audits are currently occurring for the hospice world, why that is. And then a little bit about a hospice response plan. And as Gina shared with you, we will be going into this in depth in an upcoming audit series and to help you really in terms of leadership within your hospice, take an active role in one preventing audits if you're able to, which means helping support good data. And I'll talk about what data that is in a second. And then when you're audited to help your hospice navigate that audit system. All right. So I'd love for you to weigh in in the chat if you think that the hospice industry is being unfairly targeted or audited. If you think currently that this is really just unfair, we don't deserve what we are going through. Let's see. Here we go. So it's funny as I couldn't see the chat, it doesn't help if I ask you a question if I can't see. Yes, no, yes, no. If you think that it's unfair, no. And I'd love for those of you who do not think it's unfair and take a brief stab at why it's not unfair. Why are we being audited in the hospice industry? Mostly yes, yes, unfair. No, it's a good thing that CMS needs some controls. I could not agree with you more. Because of historical fraud. Yes, or even current fraud. Unfortunately, bad players are putting us in this position. And that is for the most part true. However, even some good players are putting us in these situations, which is unfortunate fraud. Okay. Yeah, absolutely. Thank you so much for weighing in in the chat. There's been too much manipulation for hospices to make money through fraud. It is a fascinating world out in the hospice industry right now. So let's dive into that. What does that mean? Why is it a fascinating world? So in 2022, which typically this is about the look back period of two years where we see what's presented to MedPAC, et cetera, in terms of data, there was an improper payment amount for hospice of $2.9 billion. And that is a 12% improper payment rate, which is interesting because 12% is in my opinion, a pretty big number. And when we talk about the idea that there's just this huge chunk of people who are potentially doing this incorrectly. Now, do I think that the 100% of that $2.9 billion repayment was actually accurate and that those hospices should have had to repay that? No, I actually don't. There's probably a good chunk of that money that is completely inappropriate that hospices had to pay back. But I will say that this probably also does not capture a larger chunk of money that should have been repaid by hospices. So at the end of the day, this is a significant amount of money where the Medicare trust fund is, it's charged with appropriate utilization of Medicare dollars. And so hospice is definitely being evaluated in terms of our percent of improper payment rates. So what happens here? What are the denial reasons and the error categories? So when we talk about root cause description, especially for this physician audience, the vast majority of this has to do with our participation within the clinical record. And so when we talk about the error category of insufficient documentation, the number one denial in terms of root cause would be the physician's certification and recertification in terms of inadequate. But then as you go further down, the documentation does not support medical necessity. If you go further down there, it's again to do with the certification in that the physician narrative was inadequate. Then we find the face-to-face encounter documentation inadequate. The certification and recertification is missing. And that is an unfortunate low hanging fruit for auditors to evaluate and deny payment for. The face-to-face documentation is missing. And then the last would be the physician's certification was signed and dated after the claim was submitted. So just as a brief pause here in terms of the regulatory timing for the certification, it actually can be completed at any time provided that you have an oral certification, provided that it's done before you submit for payments or requirement to lawfully ask to be reimbursed for services is to have that physician's certification signed and dated. And as a reminder, when you sign and date a physician's certification, you're attesting that you either reviewed the record or personally evaluated that patient yourself in order to make your decision on eligibility. So when we talk about improper payments by state, we see my state of Texas, number one here. I'll defend us a little bit. These states are big providers of hospice care. So maybe that's why we have the big percent of overall improper payments. Although that's probably a lofty statement because we know that in terms of fraud, Texas, California, and then we'll add Nevada and Arizona, unfortunately are what we are referring to as the bad players. And in this climate, the bad players are really twofold. One, essentially no intention to provide hospice care, just the selling of licensures, transitioning beneficiaries from hospice to hospice, maybe even signing up beneficiaries that have no idea that they're terminally ill. That's one category of fraud. And then the next category of fraud will be intentionally keeping patients on service for long lengths of stay in order to capitalize on profit. So that's really the two buckets of fraud that we're dealing with now. And unfortunately, Texas and California are very good examples of bad players. Again, I'm in Texas, so I can say that. Now, in terms of improper payment rates and amounts by provider type, this is excluding hospitals. But when we talk about the unfairness of evaluating hospice, we're actually looking at this in terms of our improper payment rate, that we are really high up there in terms of other aspects within the healthcare system. But in terms of the percent rate and the amount of dollars, we are really high in the amount of dollars. So if you see improper payment rate percentage on inpatient rehab hospitals and units, they're actually higher in percent than we are, but they're not recovering the amount of payment there. Now, of course, there's discrepancy here in terms of the amount of claims that are reviewed. But in general, we are definitely on the radar in terms of there is this chunk of us that in the government's perspective, we're not doing this correctly. So in terms of why hospice, and why I said that it's not just the bad players, but it's the good players that have gotten us to where we are too, is that there historically has been this perspective in the hospice world that we are doing such incredible, amazing work that maybe we aren't the ones who should be evaluated because we're taking care of dying people. And so while I think it's an amazing field that we're in, I love it, it's my passion. I'm so grateful to be in this line of work. We as an industry have really set aside to be good documenters, compliant, achieving quality standards for a long period of time. And so this is why we really have gotten to where we are now. It is what has set the stage for bad players to be able to take over without being evaluated as meticulously as I think they should have been. So what I mean by that is really good hospices can still have really bad documentation and have really high improper payment rates. And unfortunately, when we say that it's the bad players making it bad for all of us, we have the good players, meaning people who are doing good hospice work that are not upholding the intent of those conditions for payment in terms of defending our eligibility and the clinical record. And so now we have all of these people in the mix and this is where the government is saying, well, there is money to be taken back in the hospice industry and unfortunately that's us. So the really, actually the most unfortunate thing to me is that some of this attention and auditing is actually coming from reports and complaints. And so we have had and seen very publicly families reporting that their loved ones were signed up for hospice without a terminally ill diagnosis. They were just coerced into hospice care for the provision of let's say DME. Maybe they promised them a wheelchair, oxygen, et cetera. Instead of actually talking about the fact that this was hospice, we have complaints of their Medicare identification numbers being stolen and then being filed within the hospice industry in order for them to make money off of those human beings. And so the amount of complaints that are increasing are actually driving some of our auditing world, which is very, very unfortunate. Okay. So I wanna start with understanding or helping you understand what generates an audit. Because unfortunately I see a lot of physicians say this in an interchangeable manner in terms of you'll be audited on this when it's not accurate, it's not an accurate statement. And so what gets audited, what drives an audit, it's all driven by the conditions for payment, right? So this is payment related technical compliance. In the big picture, in the big scope, it's not your quality or your conditions of participation that are going to drive an audit with the exception of what I just said, which is egregious complaints that are coming from your hospice in terms of the quality provision of care. But they're still going to come in and evaluate you in terms of auditing based on the conditions for payment. Audits don't evaluate conditions for participation. So why do you get an audit? It's data driven besides the complaints. So things like the PEPA report. And if you're not aware of what your PEPA report data is within your hospice, I would highly recommend that you start looking at that. It's to me an invaluable resource to see where your risk areas lie for auditing. And that is something that we will be doing a deep dive into in our audit series is how to interpret your PEPA report in order to mitigate risk within your hospice. So you may have aberrant data in your PEPA report, whether that be length of stay or your higher levels of care, GIP, continuous home care, maybe in an assisted living facility. Aberrant meaning you're different than your counterparts, whether that be regionally or nationally. But it doesn't mean that you're doing it incorrectly by nature. However, and this is what we call risk mitigation, it does mean even if you're doing it correctly, you are flagging the attention of CMS, thus auditors, maybe third party contractors to evaluate what you are doing to ensure that you're doing that correctly. So maybe you do a high level of general inpatient care and your length of stay is just a little bit longer than an average of five days, which of course that is not regulatory requirement by any means. You're not limited to the number of days of GIP care per patient. You know, that is aside from your cap, et cetera. But even if you're doing everything correctly, discharge planning, getting those patients out of the GIP level of care, if your PEPA data, which comes to your Medicare administrative contractors from Fathom data, it's a different report, they will then target you to evaluate what you are doing. And again, if you risk mitigate with having great documentation, pre-billing review, which is all the things that we'll talk about in the audit series in terms of how to mitigate risk, you may come out of that audit with 100% pass rate. That's absolutely obtainable. It has happened. I have seen that before. Not that common, but actually can happen. Now, in terms of certain audits are driven by other audit results. And so let's say you don't do well in one particular audit, it might drive you into another audit. Or maybe you're evaluated with one thing in terms of an audit, and they notice that you have a really poor practice pattern in something else, and then you get audited in that something else, right? Okay. So what I talked about, about what generates an audit. So we're talking about the difference between conditions for payment and conditions of participation. And so some of this might be very basic for a portion of you on the line, and some of you may be really diving into this for the first time. So it's easier to understand this in terms of one bucket, which is the conditions of participation, is surrounding the patient experience. So did we address their pain? Did we see them when we said we were going to see them? Did we provide a higher level of care when it was warranted? What were our infection control procedures in terms of our patient who did or did not experience an infection? Now, for the patient experience, which is what we talk about in terms of quality, this is evaluated in terms of survey. So if you see your patient, let's say you miss a visit, and it has been more than 15 days since you've seen the patient, and this is a condition of participation, right? That we should have an update to the comprehensive assessment every 15 days or more frequently as the condition warrants. This is an example of how people get confused between a condition for payment and condition of participation. There will be some hospices out there that say you have to discharge the patient and readmit them because you missed the 15-day window, or maybe you transferred the patient, or maybe you have a contract in place and you missed the 15-day window. That is not a condition of coverage or for payment. That is a quality provision. And so when you miss that visit, is it a big deal? Yes. Do you need documentation to support why or why not? Do you need to fix that issue? Yes, absolutely. But this is a surveyor's domain. This is something where if you had an accrediting body or maybe it's your state organization that evaluates your conditions of participation, if they pulled that patient chart or clinical record, then they would say, oh, I see that you have a visit frequency of seeing this patient twice a week, and you have no visits for 15 days. So then you would likely be sanctioned in whatever form or fashion. Maybe if it just happens one time, they wouldn't say anything to you, but if this was a recurring pattern, you may have a deficiency, maybe even a condition-level deficiency in terms of the lack of provision of care. So something else that I hear people talk about in terms of the patient experience and not quite conditions for payment would be like selecting the principal diagnosis code. And I hear people say, well, you can't do that diagnosis code or you won't get paid, or CMS doesn't allow you to do that diagnosis code. And this is grossly inaccurate. And I find a lot of physicians get really hung up on picking the principal diagnosis code. It was never intended to be a barrier to admitting patients. And so picking the right ICD-10 code is largely the least important thing that we do in my opinion. When it comes to, do I think this patient is going to die in the next six months? That's the most important decision that we make, right? So do diagnosis code generate audits in a group fashion? Yes. So let's say that you have all of these diagnoses that lie in neurologic conditions as a group. Yes, audits are driven off of neurologic conditions at times. There's only been one audit that particularly grabbed at certain ICD-10 codes and that audit has been closed. So the other way that this might be evaluated is let's say that you have a lot of cardiopulmonary diagnoses and on your PEPFAR data, you have that as your number one diagnosis. Well, that's not typical across the country when you're compared to other hospices. The fact that you're atypical in that manner would drive the audit, but not because you chose to use, let's say senile degeneration of the brain as the principal diagnosis. That in of itself will not drive an audit. But now what might happen if you have a lot of patients with senile degeneration of the brain, let's say then that correlates with a long length of stay. So then it's your eligibility, which you'll find on the right side of the screen, which is a condition for payment that drives the audit. So if your average long length of stay is over let's say 300 days, which would be quite long, then that might be something that you are audited because of Now, just as a reminder, PEPR data is not available in this year. PEPR got shut down. They're in the process of requesting further information with an RFI to see how we utilize the PEPR report. But I would wager, I guess, that we see no further PEPR data until 2025, if we see it in the spring of 2025. And someone asked in the chat, how can one download the PEPR report for our agency? There's typically one person who is designated to retrieve the PEPR report. And so I would start with asking your executive director, maybe your director of quality. They have the ability to access that report based off of your hospice provider number and the beneficiary number that you're serving, a patient that you're serving, and can retrieve that for you. As a hospice physician, my hospice knows that I want that PEPR report as soon as we retrieve it every year. And we sit down and we go through where are our risk patterns and how does it pertain to me. Again, for more on the PEPR, which I love, and is actually quite complex, we'll be able to dive into that in October. So hospice payment and focus on auditing are largely these two questions. Were the technical requirements for payment met? This is the low-hanging fruit that I talked about. Maybe there's no CTI. Maybe there's no face-to-face encounter. Maybe the dates are not regulatory. Or maybe your election statement, which we might also call consents, are inaccurate. Maybe you didn't have the BFCCQIO contact information on your election statement. A lot of hospices have gone through that in the last couple of years. Those are the black and white, check the box, did you have this technical requirement? Now the documentation supporting technical requirements surrounds eligibility under the dates of service under review, and then the correct level of care. Did you both need to provide it and provide that higher level of care? Meaning for GIP, was the patient in a crisis and did you address the crisis with your plan of care? So here are a list of the technical components. So when you say, I'm afraid this might generate an audit, you can only say that when it pertains to these elements, right? And when you see number seven here, the plan of care, it's actually just the presence of the plan of care pertaining to the dates of service under review, the benefit period in general as well. It's not, did you meet your visit frequencies or things like that? So when we talk about physicians, we're a huge component of this. We are the ones who generate if something is related or unrelated, which will generate the election statement addendum. We are the ones who certify and recertify and then fill out that physician narrative. You may or may not be doing face-to-face encounters. And then of course, as of just recently in the last six months or so, less than that couple of months, we must be credentialed appropriately in the PICO system, which means either you are opted in to Medicare or validly opted out. All right, so let's talk about audits in general. So this has to do with the Center for Program Integrity. Whenever you hear CPI or program integrity, this is an evaluation to ensure that federal dollars are being utilized in the correct manner. And something I forgot to say is please feel free to enter your questions into the chat through the entire duration of what I'm talking. I may or may not answer them as I go, but we'll have lots of time for Q&A at the end here, I hope. Okay, so when we talk about review contractors in order to execute this program integrity, this evaluation of are we spending Medicare dollars appropriately? This is where we're talking about things like comprehensive error rate testing, CERT testing. This would be not an evaluation of the provider. This will be an evaluation of the evaluators like your Medicare administrative contractors, making sure that things are being provided in both ways, good and bad, mainly on the good side for that. Then we talk about Medicare administrative contractors. If you're not familiar who your MAC or Medicare administrative contractor is, please familiarize yourself with that because it determines what local coverage determination guidelines you follow and some other nuances. I'll go through that here in the next couple of slides after that. They used to be fiscal intermediaries, used to be references that, now we call them MACs. Then the next audit type or that third party contracted for auditing would be supplemental medical review contractor. We call that a SMERC audit. Then we have the unified program integrity contractor audits, UPIC. Recovery auditors, we used to call these RACs. They, for some reason, wanted to be special and dropped the C. They're now just recovery auditors. They're not RACs, they're RAS. I can't make myself say that. They evaluate right now in the hospice industry and continuous home care and general inpatient level of care in terms of person individualized audits. Recovery auditors have multiple different types of audit in terms of simple and complex. And we'll go through that in the audit series. And then we have Medicare Part D contractors. And so these are automatic audits, meaning a person isn't involved with this. It's a direct audit that they might look at, let's say a Duoneb inhaler is billed to Part D and this contractor will say, this beneficiary was on hospice and they should have paid for this and they will send you the bill. So the only defense for this type of audit, which comes in the form of a demand letter, it might come from a company called Rawlings, which is one of the example. The only defense against this is good documentation, which must be provided by the physician according to CMS as to why that medication was unrelated. Now, if it was a mistake and it got billed to Part D, then of course you have to repay that immediately upon receipt. Okay, so let's walk through the Medicare administrative contractors. And I'm not gonna do it as specifically for the other types of audits, just for the sake of time, but we are gonna walk through these MACs for a second. So for those of you who don't know, there are three who have hospice contracts. I wish one of them didn't because they're the tougher one, but it's Palmetto, GBA, I have to remember this is recorded. Okay, CGS administrators and then the NGS, National Government Services. And so these are the entities who are charged with evaluating, delivering and evaluating the delivery of money to hospices. So we have CMS dollars, then you have Medicare administrative contractors. Those are contractors with Medicare to give us our money and they judge us if we deserve to receive that money, right? So they do a lot of our auditing. Nearly all of their audits are driven and focused on reducing their own error rate reduction plan. So each Medicare administrative contractor may have a different emphasis or different types of audits. They're all in terms of TPEs, but maybe let's say NGS's error rate reduction plan is largely focused on long length of stay and maybe Palmetto is more focused on general inpatient level of care. And so within those three MACs, they'll decide their emphasis and topics, which have to be approved in terms of what they're auditing us on. So these audits can be prepayment or postpayment, doesn't matter. Meaning you submitted for payment on your beneficiary, let's say Mrs. Smith for the month of July. And then they hold that submission for payment. So it gets held in that billing system and you see it held there and they don't release your financial reimbursement for that patient. So prepayment to you after you submit billing. And then they'll decide if you deserve to receive the money or not. And then you get your funds. If you deserve to receive the money and you do not, if you don't, if you fail, whatever audit they have. Now, postpayment will be, you've received the money, it's in the bank, maybe you've spent it already, unfortunately, and then you get that postpayment audit, right? So we have a little reprieve, a little pause in terms of COVID-19, but they are very much alive and well and resumed immediately. They are fascinating types of audits here. They're supposed to be driven by data. Now, when we talk about PEPR data and other data, you may be aware that you're high risk to receive a certain type of audit, maybe GIP or long length of stay. And you also may not know what data they're using because I've heard of providers who are in a GIP, TPE, and it's hard to even get the number of claims to be reviewed by the Medicare Administrative Contractor because their rate of GIP is so low. So it would be difficult to imagine why their GIP data drove that audit. All right. So, but typically you're going to be flagged as something that you're doing is different to hospice XYZ down the road, or in the state across the way, or the jurisdiction across the way. And in that particular error rate improvement program from your Medicare Administrative Contractor. So those of you on the line who have been in hospice for quite some time, this was supposed to replace the prior additional documentation request or EDR process. You still get the additional documentation request. It's still an ADR per se. It's just in the context of what we call a targeted probe and educate the TPE process. Now, as opposed to the old ADR process, this is much more severe in terms of consequences if you fail three rounds. So you have round one to receive your error rate, then an opportunity for education, which is typically largely not effective. I'd love to hear in the chat, if you were in a TPE and the education you received was very helpful. And then you have second round, same thing. If you don't pass their charge rate denial, charge denial rate, CDR or error rate, you will have the opportunity for education again. If you go into round three, things are very serious. And if you fail there, then you will be referred on. And this is where we mean that the consequences are severe. So for your reference, when you, and you'll have this PDF for you to keep for your own resource. And this is the cycle of a TPE program, gives you the timeframe, typically drawing 20 to 40 claims, although I've seen them close at 14 claims. Oh, Ron, you had a TPE education from CGS that was very helpful. That is so, so good to hear. I will relay that to CGS because it has been a tricky process for us lately. I hear on the education part. Okay. So this is another kind of flow as to how you walk through these rounds, round one, two, and three. You don't have to receive education if you don't want to, you can decline to receive education, but I would really recommend that helpful or not, you hear what they have to say. If for nothing else than to just show that you are receptive to the process as a hospice, would highly recommend that. You as a physician can absolutely be involved in this process. In other types of audits, this education period or a response period could be helpful in getting your error rate reduced, but that is not the case for a TPE, right? Now, if you are in one TPE type, let's say a TPE type is GIP, long length of stay, and you pass your round one, round two, or pass round three, you will not be audited on that topic for another 12 months. So you have a 12 month reprieve. Now that's not a reprieve from all TPEs, just from that topic. So you could receive multiple different types of TPEs at once, which is unfortunate for hospice providers who are still trying to provide good hospice care. So in terms of next steps for your failed TPE audit, CMS could do multiple different things here. When we talk about the trickiness of this and the high stakes arena that you're in, if you fail the third round, you unfortunately, and this is typically with really high rates of CDR, your denial, might be placed under 100% prepayment review. And so this is one of the most serious things that CMS can do as the next most serious, in my opinion, would be just to stop your ability to provide care and so revoke your license at that point. So this would mean that whenever you submit payment, let's say you have 75 patients on service for the month of July, they will look at in their timeframe, which is not immediately, your data to say, should you be paid or not? And so this typically is so challenging for hospices because you're still having to provide reimbursement to your contractors, DME, your pharmacy, your staff, your physician, for example. And so 100% prepayment reviews are typically just very, very difficult situations for hospices. They might refer you to another audit and maybe even extrapolation, which would mean that they apply the percent error rate in repayment to the entirety of what you billed. So if you billed a million dollars in the month of June, good for you, that's a really large amount, but if you reviewed that and your error rate was 20% on 20 claims, then in this example, they would take 20% of $1 million. That might be what extrapolation is. Of course, there's something called treble damages, which is they can multiply that by three. So then you might be referred into something like a UPIC, that United Contractor Recovery Auditor, or maybe they just put you on payment suspension or try to close your hospice. Now there is a TPE out there right now for, it's a probational period of enhanced oversight, PPEO. This is in place for any new hospices, which includes acquisitions for California, Nevada, Arizona, and Texas. And so this is a prepayment review of a certain number of claims for your hospice, but this is not the typical TPE process. This isn't you get three rounds. Typically you just get two rounds and then, and you might get education in between the two, but at the end of the second round in a PPEO, the provisional period of enhanced oversight, typically they're talking about payment suspension or cessation of your ability to provide care, which is unfortunate, but helpful in those states that are really struggling to be good providers. All right, what's a SMERC? So this is our Supplemental Medical Review Contractor. It's all data-driven, so SMERCs are driven by different types of data analysis. They might come from comparative billing reports. So let's say you have a hospice that provides a very high number of nurse practitioners as an attending and are billing for your nurse practitioner symptom or medical necessity visits, not face-to-faces, but those symptom visits. You might be in a comparative billing report and outlier to the vast majority of hospices that don't have nurse practitioners as the attending because they're not chosen by the hospice beneficiary and thus generate some type of audit to evaluate your hospice. All right, these sometimes maybe the OIG was poking around in your hospice for another reason and you might get identified in terms of having to undergo a SMERC. More likely if that were to happen, it would be this guy, the U-PIC audit. So U-PICs, and we just get scarier as we go along here, unfortunately. So U-PICs are designed to deter, detect, and detect fraud, waste, and abuse as they all are. It's just that this one gets a little bit scarier. It is driven by data, but also driven by complaints. This is one of those very, very high stakes audit. And so when we talk about an audit response and you choose to either weather the audit with your hospice alone, or seek to get help from a consulting firm, or maybe even a legal counsel, this is one where you need to decide, excuse me, whether you need to have some help because this is one of those ones that is potential for extrapolation, meaning they take your error rate and apply that percentage to the total number of dollars billed. And so in a U-PIC audit, let's say they looked at nine months of care of a beneficiary, it's not just that monthly thing of a TPE. And so this can get to be a lot of money very, very quickly. This is something that should be taken very seriously. Also, I've seen hospices have great results with a U-PIC. So like I said, your data may be different or aberrant, but you may not be fraudulent at the same time. It's just a little bit scary, this type of audit. All right, so the reason it's united, they can look at Medicare and Medicaid, the way that applies to hospices here. And one example would be, let's say that your beneficiary was in a nursing home and the pass-through on Medicaid to room and board was made, or however that the dual billing would be working there. And so they have the ability to look at Medicare dollars and Medicaid dollars. That's the united part of it. So recovery auditors, like I said, we get a little scarier as we go on. These are the ones where I hear people say inappropriately about other auditors. These are the ones who are fee for service. And so they recover, this is why they're called a recovery auditor. They recover a percentage of the funds that they get back. So if they bill, they review a million dollars for the government, they recover 200,000, then the auditor themselves would get a portion of that $200,000. And so many people hypothesize or postulate that recovery auditors are unfairly more difficult because they are incentivized. They actually went under a large amount of surveillance because of so many statements surrounding this. And they're actually known as pretty fair now in the arena, that it's not that your error rate in a recovery audit will be drastically different than how you were evaluated in a Medicare administrative contractor audit, which is what some people suspected. So the Office of Inspector General and Department of Justice, we're almost through this part. I know this is exciting for me, but maybe boring for some of you on the line types of audits. So these are ones though, that you really wanna know about, the OIG audits. There are three types. The first is inspection. And so this is one where you see the data brief come out. We've seen them about the election statement, the physician narrative, those types of things. The current audit that's available, there are two that we're waiting to hear data on. One is an OIG audit, was an inspection audit surrounding hospitalization in the year prior to admitting to hospice care. They're gathering that data to look at hospices patterns, and they'll give recommendations to CMS on what they found. We're still waiting for that information. The more recent data brief, which is very interesting, is looking at the general inpatient level of care. It's particularly GIP provided after hospitalization of the beneficiary. So the beneficiary was hospitalized. The hospitalization is a long length of stay compared to the diagnosis-related grouping. So let's say the DRG for acute respiratory failure says most people stayed for four days, your beneficiary stayed for 10 days, and then they came to the GIP level of care. We're looking at that. Of course, in the hospice industry, we hear of a lot of inappropriate utilization of GIP in order to assist hospitals in reducing their mortality rate or other data metrics or complexity, et cetera, in hospital metrics. And so those are two different types of audits that are coming. What will happen is they'll give us the information, they'll give us what they think, and they'll give us what they think CMS should do about it. CMS can say yes or no. Typically, they say no to a bunch of it and yes to some of it. And then you'll see new audits come out. Then you'll see the Medicare Administrative Contractor start looking at, let's say, GIP after hospital stay. That might be a potential outcome of this OIG inspection. So as an engaged hospice physician, you want to keep your eye on those things that the OIG is looking at. Now, they also have these bigger audits of 100 post-pay claims. I haven't seen one recently. We saw these in the news over the last four or five years. I had the opportunity to try and help defend a hospice against the OIG for one of these. These are to the tune of $10 to $16 million. And so these were some really, really big audits. Of course, the OIG found what they found, and then they gave a recommendation to the Medicare Administrative Contractor. And then that MAC would decide what they were going to do in terms of recovering payment. The third would be investigations, which we saw one investigation come out today in terms of egregious acts. In other words, they knew or should have known that these Medicare hospice beneficiaries were not appropriate for hospice care. They had long lengths of stay, and the government is alleging that they were not eligible for hospice for that duration. And that hospice is paying back $3.8 something million. So a lot of those investigations are generated in what we call QUTAM. QUTAM is whistleblower, and that is what this OIG report that came out today. The whistleblowers for these particular cases, whistleblowers, when money is recouped, earn money back. And so these particular whistleblowers, it was published today that they made almost $400,000 on whistleblowing on this hospice. And so just be aware that that is one way that audits are generated is based off of complaints, like from a whistleblower, and they will be protected in terms of their identity for two years. And then they will recoup money back if the government recoups money back. So that's a fascinating place to be in terms of the hospice industry. So in terms of the high-risk audits, OIG obviously is an extremely high-risk audit, and you want to consider legal counsel and representation in order to help you defend against this. There are all types of complications that come from these types of governmental audits, like personal risk, maybe jail time, for example. We have unfortunately seen some physicians go to jail here in the last few years for eligibility determination, essentially, but there was more to it, like not being the one who signed when the person's signature was clearly signed and dated on the documentation. Of course, it's a huge financial risk, and then you are putting the organization under different types of risks. So maybe you have to undergo corporate integrity agreement. This is years and years and years. So when we see this come to light today in terms of what is publicly facing, that OIG investigation likely was four or five years ago at least before we get that information. So what do you do? That's why we're here. How do you handle these things? So it's really important as physicians that we're aware of what I've just spoken about. What are the types of audits? What the climate is? What's important for you to know in terms of documentation, which is everything to do with the CTI and pre-physician narrative, but also your determination of eligibility. If, let's say, you see in your PEPRA that you have a long length of stay problem, for example. But when we were talking about an audit response, and this is something that we'll walk through extensively in the audit series, you want to ask these types of questions and make sure that your hospice is prepared. So who's responsible for ownership of this audit? And who's notified? So at Weatherby, we've heard some awful stories where like front office staff get a letter from the OIG, and they just put the envelope in a drawer, and they don't know who to tell. And unfortunately, situations where somebody comes on site to do some teaching, and somebody then shows, hey, we got this envelope a couple of months ago. Is this important? So you want to make sure that your entire team within the hospice understands in general that there are notification processes, like through the mail, electronically, by phone, and they're to be taken seriously. And everyone needs to know who's the one who owns this and responds to this so that your hospice is prepared to respond, or at least initiate that response. What's the role of the physician? I'm going to talk about that on the next slide a little bit more. How do we respond? Do you just go and print out the entire clinical record, slap it together, put it in the mail, send it off and say, you deal with it. Now there are lots of people who take that approach. And I don't recommend that you respond in anger. And this is something that's common, that you just say, you know, you figure it out, here's the record. And that will be really, really a challenging response in order to expect any type of successful result in an audit. But let's say the response does need some time. Maybe your EMR, when you print it out, it's awful. And it needs time to rearrange. You need to figure things out. Maybe you need to get some attestations because you realize that we did this right, but we didn't sign it the correct way. So do you need more time? Can you ask for an extension? Who's responsible for requesting the extension? And what type of extension is available? Do you need to retain help like legal counsel or like a hospice consulting team like Weatherby? How do we follow up? So when you have submitted this data, but you don't hear anything for four weeks, who's following up? Who's watching your NGS or CGS site, for example. And then maybe in this process, you find, hey, we have aberrant data, and there's something we need to do about it. So who's evaluating forward progress, the change needed, the education that might be needed within your hospice? So is there root cause analysis needed? Why do we have a really long length of stay at the GIP level of care? What's going on there? Where is the hang up to discharge planning? So these are all questions that you want to know in terms of your audit response system. Who's going to handle this is the number one thing you need to know within your hospice. So in terms of physician response, and this is something we're going to go through extensively in the audit series. What's the physician role here? Sometimes there's none. Sometimes you get a TPE, they want 20 records, 20 claims for a month each time. And you say, wow, these are all really good. All our technical requirements are met. And we're going to send it off in an organized fashion. And the physician has minimal involvement other than knowing that this is something that's going on. Sometimes you might look at the record. And when they say that the patient's not eligible, you look at the record and you might say, I agree. And then you guys repay. Maybe you say, no, this patient is very clearly eligible and we need to defend this. So how do you defend just by printing out the record? Maybe as a physician, you write a medical summary letter that says, in your physician opinion, why this is an absolutely eligible case that should be paid or maybe repaid back to the hospice. I highly recommend if you've never written a medical summary letter that you get some training about how to do that before you just write one. There is professional etiquette involved that really makes your letter appear to have more weight other than just saying, this is my opinion. This is why this should be paid. This is something that we'll go through in the audit series. Now, as you do the appeal process, I've talked about the submitting data, but if you are denied and there's a whole appeal process that exists that we'll go through in detail. But one of them is getting to the administrative law judge level of appeal, the third level of appeal. And this is where the physician may provide expert witness testimony. And so you might be on a call with, this is all done over the phone now with a judge, you'll get sweared in. And then they, you have the opportunity to speak to why the denial is incorrect, if that's what you believe and have that opportunity to appear as an expert witness. If you've never done that before, I highly suggest that you get a little bit of training before you do that. And that's something we will offer within the audit series itself because there are definite strategies and tactics in expert witness testimony. I think years and years ago, it was pretty sufficient when a physician got on with a judge and said, hey judge, this is my opinion, this is why. And then they ruled favorably or unfavorably. Now, it's pretty intense. I've been with some judges that are just, they're very, very intense. It seems more like I was under a, defending myself, not the hospice. So, all right. So now we have time for a question and answer. So please put the questions in the chat. Don't hesitate to ask any type of question, of course, unless you're, don't want any of that information to be shared publicly. We do have a list here of what Weatherby does. I think a lot of people think that we do education, which we do, we love to educate. But most of what we do is to help hospices defend themselves when they're in audits. And so we compose medical summary letters. I do a lot of expert witness testimony as does Kerry Cooley. And we do a lot of other types of defense strategies with hospices, good hospices, who are caught in the mix of the auditing world. Okay. Laurie, Dr. Earnshaw, I should say, what do you think the most important clinical data points are to justify terminal prognosis? So, Weatherby, we teach something called the hospice language. And so the hospice language is what, what speak we need to include into the record that an auditor understands. And so my answer to your question is, whatever the data point is, it needs to be spoken or written, typed in such a way that an auditor gets it clearly. And so I think something as physicians, we struggle with is one, if I said, so I said, so this is that they're going to die in the next six months. It means they're going to die in the next six months. Or sometimes we speak too generically or too intelligently. So if we're just listing off that this person has critical aortic stenosis, an auditor doesn't understand that this critical surface area of the aortic valve, because it's so stenotic. And now they have, let's say chest pain, syncope, all the poor predictors or high mortality predictors of critical aortic stenosis. They don't understand that like just flat out, do not get it. The auditors are typically nurses who don't have end of life training. So the number one data point that you give has to be in a manner that they understand. So if you were, so to take this a step further, if you were talking about critically aortic stenosis, where they have syncope and chest pain, can't remember the third mortality marker, just blinking on that, you would have to say, and these indicators give a, thank you, congestive heart failure. This gives them a poor prognosis, right? Or so maybe you say hypercalcemia of malignancy. An auditor doesn't understand that that has any poor prognostic indicator. Let's say it's outside of myeloma and breast cancer, and this is a lung cancer with hypercalcemia malignancy, and they were hospitalized with altered mental status. And it's refractory to your interventions, whatever you did, fluid, lysics, bisphosphonates, et cetera. They don't understand that that gives them an extremely poor prognosis. It's six to eight weeks. So you have to write, and this gives them an even worse prognosis of six to eight weeks so that they understand it. So as opposed to that, making sure it's written in a way that they understand it, it's including things like the verbiage from the local coverage determination guidelines. So not just saying they've lost weight, but actually writing this patient shows progressive in an issue, which is the phrase that they use to talk about weight loss in NGS and CGS LCDs with body weight loss of greater than 10% in the last six months. So when you write out that verbiage, almost using the LCD guidelines as a thesaurus, instead of just saying they've lost weight, you have exponentially improved the strength of your documentation and using just the verbiage from the LCD guidelines. The difference between saying, let's say they had a UTI in the last month, then to write they have had a serious infection in the last month, which was a serious urinary tract infection. The serious infection phrase will be the verbiage from the LCD guidelines. Again, you drastically change your strength of documentation. The next thing I would say is comparative data. This is what they're looking for. People call it decline. I hate the word decline. Decline is so generic. What you're looking for is how they're advancing towards their death. Why do you think they're going to die? So losing two pounds in the last month is something that I did, and I'm not terminally ill. So you have to demonstrate why that comparative data that they weigh 98 pounds instead of a hundred pounds a month ago means that they're going to die. We want to describe why a MAC drop of one centimeter means they're going to die. That signifies whatever it means to you, loss of muscle mass, malnutrition. In the context of that beneficiary, you're explaining that verbiage with comparative data, what was different now from then, why they're closer to dying, even if it's still six months away in your data. The biggest risk factor, I would say, in terms of your documentation is conflicting data. So when you write your CTI, your pre-physician narrative, and you say that it's a FAST-7C, and the RN is saying a FAST-7A, and then pastoral care is talking about how much they talk with that patient on their lovely visits and chats every two weeks, that conflicting data, it negates the weight of your documentation. So even though we say that the physician's documentation carries the most weight in defensive documentation and auditing, if everyone contradicts you, there's no weight to be had. It's that contradicting data that is the worst. Okay, I spent a lot of time on that answer. That one is a really important answer to have. Okay, the next question. Besides the audit workshop in October, what resources, where does one go to receive training on expert witness testimony for your decisions? So Hush Blackwell has a podcast that talks a little bit about expert witness testimony. I know that there is an incredible person who does expert witness testimony training for physicians online. I'm blanking as to what her name is, but I'll get it to Gina. There's an option there. That training is a little bit expensive, and it's for someone who does expert witness as a profession, but I've seen some of her information. It's really helpful, but I'm not really aware of anyone who does this training outside of what we're providing in October. This is a new training that we developed based off of the fact that it doesn't really exist. So that's why we're doing this audit series to help prepare physicians and their response in auditing. Grace Huffman, Dr. Huffman, is there any ongoing effort to require the auditors to have enough medical knowledge to not need to be spoon-fed? That is to have the auditors be a jury of your peers, essentially. Yeah, I love this. This is a big call from the advocacy groups in saying that this is absolutely essential. This is a component of the care act that is being, the Hospice Care Act that's being proposed, and this is something that the industry continues to advocate for, to say that the auditors just don't have enough knowledge to be doing their job. So this is something that's ongoing. Typically, you're never audited by your peers, with the exception of those big OIG data reports. That's the only time I've seen a hospice physician be involved in the first level of denial. Now, when you get in higher level of appealing, you might have physician involvement. And I know it's time. If anybody needs to get off, absolutely, feel free to do so. But I'll continue to answer questions if that's okay with you, Gina. Absolutely. I see one more in the chat. Okay. Can a medical director who was not part of the agency at the time of the cases audited can or should credibly defend these cases in front of an ALJ hearing? Dr. Schwartz-Peterson, yeah, absolutely. This is what I do as a profession, is expert witness testimony to help defend other hospices. So this is something that you can hire a consulting firm for, or a legal firm to help assist you with. There is an art to it. And so, you know, it is nice. That is one thing that you can have someone else take care of for you. And that's where you really come in. I testify as to my credentials and my expert opinion, and then say that I agree with the hospice physician. But absolutely, it can also be your hospice doctor in terms of, you know, that weight. Why do initial appeals through medical summary letters seem to be denied? That's a great question. So it doesn't really necessarily have to do with the medical summary letters, although to be very transparent, they're not actually required to read medical summary letters. Most do, but they are not required to. And it really all comes down to our documentation should be speaking for itself. So if the documentation doesn't speak for itself, that's typically why we want a medical summary letter to help beef up the auditor's opinion of the clinical record. That probably is more why it is denied. That's a great question. For patients that clearly meet LCD criteria, save for Alzheimer's disease with a fast of 7CM wounds, but are stably sick without obvious decline, how do you suggest documenting? That's a great question. I really looking in how Alzheimer's disease patients advance towards their death, you want to talk about increased level of dependency and ADLs want to talk about the nuances to weight loss, like their clothes are ill fitting now loose and baggy. And then you have to say, and this is evidence of progressive adhesion, just really spell it out for them. And it really has a lot to do with that change in level of dependency of ADLs. What I mean by that is a patient who was able to be sat up in a shower chair six months before now is a bed bath. And then two months later, now requires two people to do the bed bath because the contractures are so severe. And then you say, and this is evidence of how this patient is getting closer to dying. It's not enough to just say it, you have to connect those dots. But when you say wounds, it's got to be stage three and stage four wounds, right? So oftentimes what I hear us say is that they meet the LCD criteria, but they don't actually quite meet the LCD criteria. And so you want to be sure that you're looking at that. I hate the LCD guidelines. I don't use them when I prognosticate for patients. I use my expertise as a physician, but LCD guidelines are what we use to document those patients. And so it's a tricky situation, Dr. Bullock, that you're talking about. One of the things I do is if you don't know, and you need more data, get more data, grab an albumin level, get a chest X-ray on your CHF patient, you know, those types of things. If it's going to give you more information that you need, then that's something that if the data is not there for you to make your decision, then get more data. Don't hesitate to do that. Okay. I think that's all the questions. If I missed one buried in there, feel free to add to the bottom. Dr. Cross, no, thank you. That means a lot coming from you. I appreciate you. All right. Well, everybody have a great afternoon and we would love to see you in the audit series coming up in a couple of months now. We will really dive into more of those things. We're still in the content creation portion of the series. And so if you're planning on attending and there are things that you really want to hear about, we would love to hear about that from you, any specific questions that you have, so that we can make this really a very, very high yield resources for hospices. This isn't just for physicians, it's for your C-suite, anyone in your hospice that is involved in audit responses. And so, you know, please don't hesitate to reach out if you're in an audit and you need assistance, of course, feel free to reach out to Weatherby Resources and we can let you know how we can or cannot help you. All right. Have a wonderful day. It was an honor and a privilege to speak to hospice physicians. Take care.

hospice audits

navigating audits

documentation

LCD guidelines

eligibility criteria

expert witness testimony

ALJ hearings

Alzheimer's disease

clinical decision-making

audit workshop