Name: Audit-Ready Before the Auditor Calls
Uploaded: 2026-03-26T17:46:05.245Z
Duration: 30 min 28 s
Description: Audit-Ready Before the Auditor Calls

Transcript for "Audit-Ready Before the Auditor Calls": Hello. Welcome, everyone. We're gonna give a couple minutes for people to come on in. I'm Susannah Vogel. I'm gonna be moderating today's session. Just so you get acquainted with the platform, we have a nice q and a feature on the side. If you'd like to introduce yourself and let people know where you're tuning in from, this is also a great space to ask questions throughout. We'll be paying attention to that. We're gonna give it a couple minutes before people before we get started to allow people to log in. We also have in the docs section a direct link to book a demo with Beryllium if you're interested after this session and wanna learn more about how we work with hospices. Okay. Let's go ahead and kick it off. And then as people come in, they can join the conversation. We have a lot to get into in this next half hour. So thanks again for joining me. My name is Susanna Vogel. I'm the content marketing director here at Beryllium. Now, it's no secret that hospice owners have been under increased scrutiny this year. More than half of Medicare hospices faced multiple simultaneous audits last year. CMS has already revoked billing privileges from 122 hospice agencies, and CMS is expanding its reviews this year. Today, we're joined by Zaina Niles, attorney at Hush Blackwell, to unpack what's actually driving the uptick in scrutiny, what documentation creates vulnerabilities during audit, and how hospices can act today to reduce their risk. So let's dive into it. First, welcome, Zaina. Can you please share a bit about yourself and how your team helps hospices prepare to respond for audits? Absolutely. Well, first of all, Susanna, thank you and Brelium for inviting me to talk about this very timely topic. I have a background in I have an MHA, an MBA, and a law degree. So I always knew I wanted to work in health care law, but I feel very lucky to have landed in the hospice space. It's extremely morally fulfilling working with providers who do such important work and care for our most vulnerable populations. So Hush Blackwell has a very robust hospice and palliative care team. I'll talk about a couple other folks on the team. We have Brian Nowicki, who's been doing this work for more than twenty years at this point and sort of heads up our hospice group. We also have Andrew Brenton, who does a lot of internal investigations, overpayment analysis, regulatory compliance questions, and also just general risk mitigation strategies, like reviewing key forms for compliance. And I know we're gonna talk about those key forms, later today. We've also got Adam Royal, who is our transactions guru, and he assists with purchases, sales, enrollment updates, all of that good stuff. And then my bread and butter is the audits and appeals space, and so that's gonna be the focus of our conversation today. And so what that entails is helping hospices produce complete and organized records as a part of their record request responses, advising about options for handling audit related overpayments. I also work with hospices to draft appeal documents to rebut and try to overcome any clinical and technical basis for denial, appear as an appointed representative for hospices at administrative law judge hearings, and then also advocate with CMS and its contractors in the audit context. And, of course, there's lots of other experienced attorneys and paralegals who are knowledgeable about hospice and really passionate about this type of work. K. Well, thanks for that background. It sounds like you've really seen it all. At the start of this conversation, I mentioned that we've seen an uptick in nationwide audits of hospice and regulatory scrutiny. I'm curious. Is that showing up in your day to day? Absolutely. To say that we have been busy on the hospice team would be an understatement. So we're working with hospices all over the country to help them weather the storm, and it really is a big storm right now. And one aspect of that, as I mentioned, is assisting them through the many, many different types of both pre and post payment audits that are going on right now, both on the Medicare and the Medicaid side. And so we've most certainly seen an uptick in audit activity across the board. And we've also noticed that auditors have steadily grown more aggressive in terms of denying hospice claims for both clinical and technical reasons. Can you help us understand what's driving that surge of scrutiny, and are certain hospices being targeted more than others? Well, hospice has been under the microscope for quite a while, but recently, we've seen an increased focus on rooting out fraud, waste, and abuse. And I'm sure everyone who's tuning in today, or watching the session on demand later is following the news. And so you're aware of the the activity that's going on. But just to hit a few highlights, over the past couple of years, CMS has revoked billing privileges of nearly 300 hospices just in the state of California, which has been referred to as the, quote, unquote, ground zero for hospice fraud, particularly Los Angeles County. There was a congressional hearing back in February that focused heavily on health care fraud, including within the hospice industry specifically. And just a couple weeks ago, doctor Oz announced a campaign to identify and also decertify fraudulent hospice providers, and he's been visiting providers in, quote, unquote, problem states like Nevada and California. The DOJ is also ramping up its investigations, and The US House Of Representatives Committee On Oversight And Government Reform has launched an investigation into hospice fraud in California. And I could go on and on about this all day long, but California providers are really, really in the hot seat. But we are seeing enhanced oversight of hospice providers nationwide. And so a couple specific examples of that, we have the provisional period of enhanced oversight reviews of new hospices in California, Nevada, Arizona, and Texas, and now also Ohio and Georgia as of the 2025. We're also seeing a lot of the the sister type of audit to PPEs, which is expanded prepayment reviews, sometimes called targeted high risk reviews of existing hospices in those same six states. And both of those prepayment audit types are conducted by the Medicare administrative contractors, and it's possible and probable that they will expand into additional states in the future, like maybe Minnesota or Florida. Mhmm. So we're keeping our finger on the pulse there. And then there's also been an increase in audits initiated by CMS's Center for Program Integrity and Unified Program Integrity Contractors. And we don't have a ton of insight into what algorithms CMS and its contractors are using to identify hospices for review. It's a bit of a black box. But what we do know is that they're casting a very wide net, and so many long standing compliant and reputable hospices are getting caught up in this and being subject to some pretty draconian consequences like payment suspension, revocations, etcetera. I'm so glad that you said that because, you know, there is this focus on fraud, waste, and abuse and rooting out bad actors. But you're right. Like, this this wide net is catching everybody, and and I think the whole industry is feeling the weight of the moment. Can you tell me, from your experience, what auditors are actually citing when when they take a look in their reviews? What's causing denials? Maybe let's start on on clinical grounds. What are the common patterns that you're seeing there? Sure. So the biggest category is an unfounded expectation of decline. So whether they're looking at several years of service or a single claim period, it is very clear that the reviewers think that there needs to be objective measurable decline in each month of service or even each benefit period in order to justify the propriety of services. But we know as people who work with HASSA's clients every day that that decline is not required in every single benefit period, that the disease trajectory is different for each primary hospice diagnosis, and so there could be an appearance of decline that does not mean the patient is no longer terminally ill such that that patient should remain on service and not be discharged. And the reviewers really don't understand the clinical realities of hospice medicine in that way. We also see a lot of misapplication of the local coverage determination guidelines. So there are three different MACs, each of which has their own hospice LCDs. But across the board, the reviewers will treat those LCD guidelines as requirements rather than guidelines. And so, for example, in an NGS or jurisdiction, if a patient doesn't tick every single box of the clinical factors listed in part one, you might get a claim denial saying the patient is not terminally ill, even when that's really just a list of examples that could support terminology if present, not a list of requirements, and not an all or nothing checklist for eligibility. And there's also an overreliance on quantitative objective data alone. So really focusing in on FAST scores, PPS, and weights Mhmm. to the exclusion of other key clinical data documented throughout the record that's relevant to prognosis and that would have been taken into consideration by the certifying physician at the time of certification. So a lot of things the reviewers very regularly get wrong, and I wouldn't be surprised if the folks tuning in today have seen these exact denial bases listed out in their audit decisions recently. Yeah. One thing that we hear at Beryllium is that auditors will say, you know, that a patient isn't terminally ill. They, you know, a patient has a chronic condition, but, you know, they're they're really not meeting the standards for a terminal diagnosis. How do you address that misunderstanding, and what should hospices be doing to push back? That is another really common trend that we've seen as well, Susanna. It's almost copied and pasted across every claim denial. The reviewer will say something like, although this patient had a chronic illness, they were not terminally ill. And so they're really attempting to create this false dichotomy between chronic and terminal. Mhmm. But most patients who are getting hospice care will have a primary hospice diagnosis that is a chronic condition, like COPD, Alzheimer's disease, etcetera. But what makes them eligible for hospice is the fact that that chronic disease has reached its terminal or end stage. So when I see denials like this, which is, again, is very often, it really shows that the reviewers don't understand, once again, the clinical realities of hospice medicine or the standard of eligibility. And it's almost another way for them to deny claims based on an unfounded expectation of decline. They're essentially saying because this patient experienced stability in XYZ discrete clinical symptom, they weren't terminally ill. So to try to avoid this type of denial, hospices really want to focus on having their clinical records, for example, their nursing notes, include details, numbers, and comparisons across time, not just generalized or repetitive statements. And then in terms of the physician narrative within certifications of terminal illness, you want your physicians to provide a synthesis or a very explicit explanation of why the data points that they're citing altogether support a prognosis of six months or less if the illness runs its normal course. Yeah. Following up on that, I'm curious what good terminology documentation includes that maybe clinicians aren't regularly capturing. Is it weight loss percentages, fast scores? You know, what would you recommend folks tuning in today? Really check their documentation in documentation includes. Sure. So this is another response that we could do a whole separate webinar on this topic, but I'll I'll try to hit the highlights. So you really wanna include evidence that paints the picture of terminology, and that's very nebulous, I know, but so what does that mean? That means as evidenced by statements. So for example, it's not enough to say the patient was in pain. How do you know they were in pain? Is it because they were grimacing? Is it because they were crying out? That's just one example. You also wanna have consistency across your documents and disciplines. So the reviewers are getting a little bit more savvy over time, and they're picking up on discrepancies between weights, mid arm circumferences, FAST scores across documentation, and they'll cite to that as a reason why the hospices documentation is inaccurate and therefore didn't support terminology. You wanna document new onset or worsening signs, symptoms, and conditions, but also any interventions that were required because of those changes and the patient's response to those interventions. I'll see comments like, well, the patient wasn't in pain. The patient's pain was adequately controlled with medication. But they're overlooking the fact that the patient's pain was controlled because the hospice was constantly titrating up their dosage to ensure that pain remained under control. So being really clear about, what heightened interventions are needed to palliate any ongoing or worsening symptoms. Recent acute events, so that means things like falls, infections, wounds, any higher level of care episodes. We talked about quantitative information, like measurements and scores and any available lab test values, and this is another area where you wanna ensure consistency across documentation. Yeah. Oh, did you have. something to add? It's gone. Jump in at any time. On top of the quantitative information, we also want to provide qualitative information, like comments about the patient's physical appearance or behaviors, things that aren't going to be captured by a weight or a MAC or a fast score. So maybe a patient can't be weighed because it's not safe, to do so. Will you still wanna document visible signs of weight loss or nutritional declines, such as temporal wasting, more loose fitting clothing, you know, they had to get a new set of dentures, bony prominences, etcetera. And then any other factors identified in the applicable jurisdiction because those are things that the reviewer, incorrectly so, is gonna treat as a checklist, and you wanna be able to have them tick those boxes. And then finally, a catch all here, any changes or declines in condition over time as well as the prognostic significance of those changes. So don't just say this Alzheimer's patient is taking longer to eat. You wanna explicitly state, you know, this is a sign of ongoing cognitive decline for this patient. Yeah. I often hear that you want auditors or reviewers to have to make as few leaps as possible to understand your documentation. And I really like how you just said, let's paint the picture. Let's make it as clear as possible what's happening with this patient. If you don't have the quantitative data, show it in how their clothes are fitting. That that's very, very clear and helpful feedback, I think. Beyond clinical denials, there's a whole realm of technical denials that can occur as well. Can you tell me what you're seeing there? What are some patterns that are maybe on the rise? Sure. So the first one is missing or overlooked documentation. So a hospice will put together their record request response, send it off, and then get an initial denial that says XYZ document was missing. Mhmm. So on the front end, this really highlights the importance of having a well organized record request response to prevent any omissions or perceived omissions on the part of the reviewer because those are fairly common. In terms of actually flawed documentation or allegedly flawed documentation, the reviewers are really focused in on election statements right now. They will cite two missing content elements. We're also seeing an increase in denials related to invalid or incomplete election statement addendums. The big one right now that has increased significantly, I would say, in the last six comments about the physician narratives and the certifications of terminal illness being invalid because they don't synthesize or explain why the clinical findings of the face to face encounter support a terminal prognosis. And then probably the the fifth one that we see the most often is comments related to insufficient face to face encounter documentation, either that it was signed or dated after the certification, or that it has a missing or incomplete attestation by that clinician. I was surprised to hear that the election statement addendums were being more carefully reviewed. What's your guess as to what's going on there? Sure. So one of the new requirements in October 2020 was that you have to include an option for the patient to request an addendum that contains patient specific information about the hospice's coverage responsibility. So your election statement should identify that option to the patient to elect this addendum. Mhmm. And the addendum has its own long list of requirements including, among other things, a a specific title and a time frame for provision. And so over the last six months or so, we're seeing more and more addendum related denials. And just to give a few examples of what that might look like, let's say that the patient or representative checked a box on the election statement that they wanna get that addendum, and then the hospice just didn't include the addendum in its ADR response. Mhmm. That might be a scenario where you get a denial based on an omitted document. Second scenario here, the addendum was provided, but it wasn't timely. So under the regulations, you have to provide that addendum within five days if it's requested in the first five days of hospice election, and within three days if it's requested any time thereafter. And then last but not least, this is probably the most common one. They'll say that the addendum is incomplete and that it either doesn't have the date furnished, which is one of those required content elements, or it doesn't contain a written clinical explanation of unrelatedness. So a part of that election addendum is you have to identify items, drugs, and services that are unrelated to the terminal illness and related conditions. And then it also must be accompanied by a plain language explanation of why that item, drug, or service is unrelated. And a lot of times, I'm seeing hospices give a list of unrelated items, drugs, and services, section. And that is just not gonna cut it in the eyes of a reviewer and is gonna result in a claim denial. This is when I wish that we had scheduled an hour because we have so much more that I wanna get into, but I do wanna make sure that we leave a little bit of time for questions. So before we pivot to that, if there's a hospice owner or a compliance team listening to this call and they wanna take one or two concrete steps this week to reduce their audit risk, their denial exposure, where would you tell them to start? Sure. So broadly, I would say you wanna be proactive, not just reactive. And there are two things that immediately come to mind as as action steps here. First, you wanna carefully review your key forms for compliance. Most notably, your election statement, you wanna make sure that it complies with 42 CFR four eighteen point two four. And that's something that you can do internally or you can work with legal counsel. Hush Blackwell regularly reviews and provides recommendations about how to update elections and ensure that they meet requirements and also minimize the opportunities for human error in the completion of those election statements. The second thing that comes to mind is prebilling reviews. So you really wanna make sure you're crossing your t's and dotting your i's before you're dropping claims. And because of the unique interdisciplinary team structure of hospice care, hospice records are voluminous. So depending on your census, I know that it can seem like a daunting task to undertake prebilling reviews, but you can be strategic about this. For example, selecting a representative sample of charts to review. If you wanna be more comprehensive, you could also bring in a consultant to share that workload. I understand from our conversation, Susanna, that Brelium has an automated prebilling review process that can help identify deficiencies across records, which is important not just to ensure payment, but also to catch any areas for improvement and opportunities to educate and reeducate staff on pain points to prevent those errors from happening again in the future. And so I would really encourage the audience to check out what both Hush Blackwell and Beryllium have to offer in terms of compliance and preventing audit denials on the front end. Yeah. Absolutely. And if you are interested in learning more about how either of our teams can assist in your compliance story, we'll be sending an email out after this event, where you can learn more about how our teams can assist you. So stay tuned for that. Now in our last couple of minutes, I do wanna take a couple audience questions that are submitted in the chat and were sent in on registration. So first question is, do you anticipate any changes to the PPEO EO process? I'm not sure what that might be. You did hint that we would see some expansions to this. Anything else beyond that? Yeah, beyond just broadening into other states, I think we are going to see some changes in the process as Palmetto gets more involved in conducting PPER reviews. Those initial four four states, we had three in NGS jurisdictions and only one in a Palmetto jurisdiction. We added two more Palmetto states, and so that MAC might take a different approach than NGS has up to this point, but we just don't have a ton of insight into that yet because they relatively recently were were brought into the fold. But I think we're still going to, unfortunately, see a lot of those very severe consequences for not meeting that 20% error rate threshold, including a 100% prepayment reviews, revocation of billing privileges, payment suspensions, etcetera. Mhmm. So CMS has been beating the drum about fraud, waste, and abuse in hospice. However, one viewer has pointed out that they've been a bit ambiguous in what standards reviewers should be using for clinical guidelines. Do you predict that we will clear some of that ambiguity up in the coming months? What do you think? Well, I hate to be such a negative Nancy. I feel like I've been the bearer of bad news throughout a lot of this call, Susanna. I think most most likely, we're not going to get any more clarity than we have right now. And inherently, hospice is more of an art than a science. It's forward looking. We're asking our clinicians to make an educated guess about what's gonna happen in future benefit periods based on the information we have right now. And so that's not an exact science, and we're never gonna be perfect at it. I think the most guidance, like, concrete guidance that you're gonna get from CMS is those LCD guidelines, which we know the reviewers and the administrative law judges rigidly adhered to despite the fact that they are guidelines, not requirements. And so to the extent that you can and that your clinicians are seeking clarity, print off that applicable LCD and hand it out to your clinical staff as a refresher of the types of clinical information that they need to be putting into the chart whenever possible. Alright. And your last question, we did not talk about this in the prep call, so I don't know. We'll see. So CMS has embraced AI in its review processes in some places. Like, Wiser is a great example of that if you're familiar. How do you think CMS will look at AI for chart review purposes in hospice if you thought about it? This might be a better question for you, Susanna. I will say, historically, the healthcare field is drastically lagging behind other industries in terms of any advancements or adoption of technology. So I wouldn't be surprised if, health care, including hospice, ends up sort of being behind the curve or late to the party on all of these AI developments. But that's sort of a non answer. I'll pass? it to you if you. have stuff to add. it back to me. What I'll say is that this administration has been interested in using AI for chart review in other areas, so they could be interested in hospice. But if you have questions about how to implement AI for chart review in a way that your agency feels comfortable with, this is a great place to bring in legal counsel and talk about it. Or talk to Barelium about how we make it compliant and and protect your information. We are out of time, so I just wanna say thank you so much, Zaina, for joining us. This has been a fantastic conversation. If you have follow-up questions, please reach out to the Beryllium team. Thank you, Alright. Susanna. Thanks, everyone. Take care.