Hospice Audit Readiness: Proactive Steps to Avoid Denials

In recent years, hospices have faced an increase in Additional Document Requests (ADRs) and audits from organizations such as Supplemental Medical Review Contractors (SMRCs) and Unified Program Integrity Contractors (UPICs). Then there are the Targeted Probe and Educate (TPE) process, and Recovery Audit Contractors (RACs). These reviews are driven by data analysis, industry growth and concerns about fraud and abuse. For hospices, preparation is key to navigating the audit process successfully and avoiding denials.

Hospices must meet specific documentation requirements to support Medicare Hospice eligibility. These include:

• Medicare Conditions of Participation (§ 418.200): Covers the election, certification process, eligibility and plan of care processes.
• Medicare Benefit Policy Manual – Chapter 9: Details document language requirements, time frames and documentation requirements.
• Medicare Claims Processing Manual – Chapter 11: Provides billing guidance.
• Medicare Program Integrity Manual – Chapter 3: Outlines signature requirements and audit protocols.
• CMS Transmittals: Updates regulations and documentation expectations.

Pre-ADR Preparation

Take proactive steps to reduce the risk of denials before receiving an ADR. Maintain accurate contact information with CMS, as incorrect addresses can lead to missed audit notifications. Review all regulatory documents in electronic and printed version to ensure all form requirements are met and content is easily seen. Conduct pre-claim reviews to verify all technical and eligibility requirements are met before submitting claims. Obtain a History and Physical (H&P) for every admission to support the need for hospice care. Develop a discharge plan for every beneficiary to prevent prolonged stays due to social determinants. Provide crucial documentation training for physicians and clinicians on Certification of Terminal Illness (CTI) requirements, face-to-face encounters and Local Coverage Determination (LCD) criteria.

Encourage physicians to create original certification narratives instead of copying and pasting documentation without adding their own assessment or prognosis. Regularly update care plans to reflect ongoing changes in the beneficiary’s condition and justification for ongoing care. Educate clinicians to address abnormal assessments promptly and to document interventions for changes in vital signs or symptoms to strengthen the case for hospice services. Resolve discrepancies in clinical data to ensure consistency between the clinical team, nurse practitioner, and physician documentation.

Preparing ADR Response Packets

When an audit request arrives, prompt and organized action is crucial. Establish an audit response team with assigned roles for document collection, packet assembly, auditing and tracking results to streamline the process. Organize documents efficiently using dividers, headers and templates for response consistency.

Follow the specific ADR instructions, as different audits require different documentation. For example, one audit type may request e-sign policies, while another may ask for evidence of core team participation in the plan of care updates. Utilize digital tools to help the compilation and editing of packets for electronic submission. Include supporting evidence, such as graphs, abnormal vital signs and documentation of decline, to strengthen eligibility claims. Keep copies of submitted documents onsite for tracking and future appeals if needed. Since each request has a strict deadline it’s important to remember to submit ADR responses timely.

Common Denials and Appeals

Denials generally fall into two categories: failure to establish a prognosis of six months or less in the documentation and technical errors. Invalid certifications happen when physicians fail to synthesize clinical data support a prognosis of 6 months or less, copy prior notes or other’s notes or use check boxes without relevant information for that beneficiary. Inconsistent or unchanged RN notes can be problematic as each note should stand alone with updated clinical information. Signature issues, such as missing, misplaced or incorrectly dated signatures, can result in denials. Face-to-face encounter errors may occur if encounters are not completed within the correct timeframe relative to certification or use the incorrect language in the attestation. Missing or incomplete addendums. Election statement errors such as missing the required language effective 10/1/2020, blank effective dates, wrong effective dates and unsigned documents are not uncommon. Missing the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) contact details can lead to rejections.

Strategies for Appeals

If a claim is denied, the appeal process is the next step. Write a strong appeal letter to address the MAC denials, include claim details and clearly explain why hospice care was appropriate. Highlight clinical changes by indicating how the beneficiary’s condition worsened by referencing symptom management, physical, nutritional and functional changes, abnormal vital signs, increased care needs and especially the hospice interventions that supported their end of life and may have prevented emergency room or hospital visits.

Address misinformation when a denial cites incorrect LCD guidance or a misapplied regulation. Clarify with supporting documentation or regulations. Involve medical directors and attorneys early in the process as you build a strong case. A physician’s input can strengthen clinical arguments for their decision on certification/recertification, and legal counsel will guide you through the process and complex situations.

Prepare for Administrative Law Judge (ALJ) hearings. The MAC may present alternative scenarios for a beneficiary’s condition and hospices must be ready to justify their care decisions. Limiting attestations is also recommended. ADR reviewers rarely accept attestations after a claim has been submitted unless they are contemporaneous with the event.

Data-Driven Defense

Track key metrics that can influence audit outcomes. Length of stay is a significant factor, as longer stays are more likely to be scrutinized. The diagnosis mix and care setting may impact eligibility assessments. Visit frequencies and after-hours utilization support the need for hospice services.

Final Thoughts

Hospices must stay vigilant in their documentation practices to reduce audit risks and successfully navigate ADRs. Proactively addressing documentation issues and implementing a robust pre-claim review process are key to surviving audits. If audited, prepare structured audit processes and responses. If denied, build strong appeals with information supporting the physician’s certification decisions. Organizations can better defend their eligibility determinations and maintain compliance with Medicare regulations when implementing these processes.