Should I Unplug the Phones Again: Understanding Government Hospice Audits and “Pre-Tecting” Your Organization Through Robust Provider Documentation (TH303)

Abstract

•Describe 3 common legal avenues federal and state investigators and Medicare contractors use to target hospice organizations.•Discuss commonly encountered barriers to adequate nursing documentation in hospice care.•Demonstrate 4 evidence-based tools useful for supporting prognosis in patients near the end of life. Since the inception of the Medicare Hospice Benefit, hospice has grown to serve over 1.6 million people per year at an annual cost of over $15.8 billion dollars. This high price tag has led to increased scrutiny by federal and state regulators over the past decade. Documentation by bedside and interdisciplinary team clinicians represents the vast majority of data in these inquiries. Unfortunately, nurses, nurse practitioners, and physicians have been trained to document clinically relevant information without always understanding the impact that this documentation will have during payer audits sometimes years later. How can hospice clinicians further not only their clinical information needs but also protect the organization should an audit occur in the future? In this concurrent session, a healthcare law attorney with 25 years of healthcare and hospice experience will partner with a hospice's nurse manager and 2 HPM physicians who have reviewed hundreds of thousands of pages of hospice records under government audit to share strategies to support effective documentation of eligibility. The False Claims Act and hospice-focused program integrity initiatives will be examined and the role of recovery audit contractors (RAC) and zone program integrity contractors (ZPIC) will be presented. Our nursing leader will address barriers to effective nursing documentation, which constitutes the vast majority of clinical information, including difficulties with technical Local Coverage Determinations, struggles around complex prognostication, and limitations inherent to hospice electronic medical record systems. During the second half of the interdisciplinary presentation, the physician team will present 4 evidence-based tools and articles that cut across disease states that will inform prognostic abilities of physicians completing Certification of Terminal Illness (CTI) documentation and support their prognostic claims. They will use examples from real cases showing well- and poorly written face-to-face and CTI notes, reworking those with opportunities for improvement using the presented tools to reinforce audience learning.