Ruth Thomson, DO, MBA, HMDC, FAAHPM, FACOI: No financial relationships to disclose
Bryan Nowicki, JD: No financial relationships to disclose
Key Message: Medicare audits aren’t going away. This presentation provides practical guidance, from a legal and clinical perspective, to maximize hospice physician expertise in the audit and appeal process. This session will cover forensic reviews of medical records, strategies for preparing persuasive written patient summaries, and tips for testifying at ALJ hearings.
Abstract: Government scrutiny of hospice will continue. Government reimbursement levels are insufficient to provide fair revenue to providers, and government audits have become a cost of doing business. Every penny matters. This presentation offers approaches for cost containment, operational efficiency, and revenue recovery so that hospices can continue to deliver essential services to the most vulnerable patients.
This presentation will address the role of physicians in hospice clinical determinations, and how hospice physicians can contribute to audit preparation. We will discuss how to develop systems to analyze medical records and auditor decisions in light of what is most effective in the audit appeal context. Your medical records offer stronger support for patient eligibility than you would expect from reading an auditor determination. Auditor decisions are vulnerable to critique. We will explore preemptive documentation practices, how to best “tell the patient’s story”, and how to transform that documentation and the patient’s story into persuasive advocacy.
Effective audit appeals require more than summarizing a medical record. This presentation goes beyond that baseline and introduces proactive “outside the box” appeal strategies that result in more forceful and persuasive advocacy. We will deconstruct the audit and appeal process through interactive discussions and demonstrations so that participants gain both knowledge and experience in implementing these ideas.
References: • 42 C.F.R. Ch. 418 regarding hospice care • 42 C.F.R. ch. 405 regarding audits and appeals • Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 9, §§ 40.1.5 and 40.2 relating to general inpatient care and continuous home care
Learning Objectives:
Develop systems to analyze medical records and auditor decisions in light of what is most effective in the audit appeal context.
Craft persuasive written audit and appeals summaries and deliver compelling ALJ testimony.
