Patient eligibility is a frequent focus of hospice audits, but it can be a challenging point for providers to prove.
With that in mind, providers should proactively prepare for patient-eligibility questions, especially as government watchdogs crack down on bad actors. Aside from strong documentation, insight from hospice physicians around patient conditions is a key defense in appealing audits, experts say.
“Your job isn’t to summarize the medical record. It’s really to tell that [patient’s] story,” Meg Pekarske, hospice attorney and partner at Husch Blackwell, said during a recent podcast from the legal firm. “It’s incredibly important to have hospice physicians explain more of the ‘why’ behind eligibility and make the connections.”
Careful attention to documentation is essential to avoiding potential audits by the U.S. Centers for Medicare & Medicaid Services (CMS) or other agencies. Documentation can also be pivotal to ensuring patients’ Medicare eligibility, which is, again, one of the most frequently targeted issues by auditors.
At the core of most hospice audits is whether the medical record supports the patient’s eligibility, according to Pekarske. Physicians play an integral role in connecting the dots between a patient’s medical record and their hospice eligibility during an audit appeal process.
“There’s value in what they can add in being patient advocates,” Pekarske added.
Hospice audit activity stalled during the pandemic, as CMS suspended audits and medical reviews by Medicare Administrative Contractors (MACs). Enforcement activity has since resumed, and even saw an uptick last year as regulators increasingly zeroed in on the hospice industry.
Additionally, hospice organizations are under more legal and regulatory scrutiny related to medical necessity complaints under the False Claims Act and the closely related anti-kickback statute. A leading cause of fraud allegations involves hospices billing Medicare for services that patients were not eligible to receive.
The question of patient eligibility is central to regulators in fraud allegations and audit appeals, according to Bryan Nowicki, Husch Blackwell hospice attorney and partner.
Auditors are always going to focus on clinical eligibility for hospice, he said, but documentation and backing with physician insight can strengthen appeal efforts.
“Eligibility is the core inquiry of whistleblowers, of government investigators,” Nowicki said during the podcast. “It’s a real gray area, which makes it ripe for inquiry, because no matter how strongly the hospice documents, there is always room to critique it. It’s not black and white. It’s important to put together a really solid written patient summary, and work with the hospice physician to do that.”
Hospice eligibility will be the focus of a nationwide audit that the U.S. Department of Health & Human Services Office of the Inspector General (HHS-OIG) has planned for next year. During the calendar year 2023, OIG will shift the focus of audits on patients who did not have a hospitalization or emergency department visit prior to electing hospice.
During the audit, hospices will receive requests for Medicare claims and associated documentation.
Hospice physicians putting their clinical analysis in writing can tell a larger patient story and aid in how regulators understand their eligibility. Being prepared to advocate for patient eligibility with physician insight to back medical record documentation is “critical” and gives a hospice a leg up in the appeals process, according to Nowicki.
Aside from clinical insight to support medical records, hospices need to have more than data to provide a complete picture of the patient’s health trajectory when it comes to eligibility, according to Ziana Niles, an associate on Husch Blackwell’s Healthcare Regulatory & Compliance Counseling team.
“What you want to do is add to that very limited picture that’s painted by reviewers to make it clear all of the factors that went into eligibility consideration,” said Niles. “It’s more than data points, but providing an analysis and explanation of what those conditions mean for the trajectory of a terminal illness. Help reviewers visualize the [patient’s] overall condition and complete medical picture by adding in details.”
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