Eli's Hospice Insider

Published on Tue Oct 19, 2010 PDF

A thorough ADR response may require adding information from before or after the dates of review.

ZPIC audits are targeting hospice providers and hitting them hard. Are you prepared to guard your claims against this new threat?

The Zone Program Integrity Contractor audits are hospice provider's biggest issue now, even more so than targeted medical reviews, says Mary Michal, with Reinhart Boerner Van Deuren in Madison, Wis.

Why? ZPICs can look at a sample of charts (30 is most common) over a multiyear span. If any of the claims they look at are found ineligible by the ZPIC, they can extrapolate those findings out to the hospice's claims for that entire multi-year period. The resulting denials could threaten the future of some providers.

1. Make certain you've established the correct terminal diagnosis. If you don't have the correct terminal diagnosis at admission you won't be using the correct local coverage determination (LCD) guidelines and hospice assessment scales to evaluate and document eligibility, says Joy Barry, RN, M.Ed., CLNC with Weatherbee Resources and Hospice Education Network in Hyannis, Mass. Moving forward with the wrong diagnosis will also take a toll on the quality of your care plan. In addition, using the wrong terminal diagnosis can impact your ability to determine what services are related or unrelated to the terminal illness, and which are palliative vs. curative.

In the past, determining the terminal diagnosis was one person's decision -- based on the intake call or the nurse's first visit, Barry says. Now, it's a better practice to determine the patient's terminal diagnosis as a team, including input from both the hospice physician and the admitting physician. Admission, like discharge, is a process, not an event -- and that process should include the entire interdisciplinary team, she says.

2. Make sure your documentation clearly supports the patient's hospice eligibility and level of care. Does the patient meet the requirements for a six month prognosis? Does the documentation support this? If the patient's condition doesn't meet the LCD, your documentation must demonstrate why they belong in hospice, says Michal.

Tip: Suppose you are looking at just a one month period in an audit, but something like the patient's death or any other major change in condition -- such as a patient contracting pneumonia -- occurred four days later. That change in condition is still relevant, Michal says. Pulling together the documentation to respond to an audit or ADR takes some thoughtful clinical judgment.

Documentation must be solid on two ends: clinical andtechnical,Barry says. On the clinical side, this means following the LCD guidelines, determining a proper diagnosis, using the correct assessment scale, thorough care planning and documentation that supports limited life expectancy.

On the technical side, this means you have completed your notice of election and the certification and recertification of terminal illness in a timely fashion on valid forms in a way that meets regulatory requirements, Barry says. Ditto for the physician narrative statements.

Why? Technical issues can cause denials without any question as to eligibility. Take an honest evaluation of your hospice and your competencies in responding to ADRs and denials, Barry suggests. If you can't handle these situations effectively on your own, get help.

3. Assign a coordinator or point person who is responsible to monitor claim status daily and to respond to ADRs and claim denials, Barry says.

Suppose your hospice used up every day it has available to submit data or request an appeal. If the adjudicator also used all the time he is allotted to determine whether a claim is payable or not (in the case of an ADR) or to deny an appeal, the process could stretch on for as long as two years, Barry notes. If one claim goes through the entire appeal process from redetermination to review by an administrative law judge, your hospice could enter a new cap year and could wind up not being able to keep the payment even if the judge rules in favor of the hospice, she says.

So, whether you're responding to an ADR or a denial,it's important to submit your response quickly and thoroughly, Barry says.

Tip: When responding to an ADR, you should carefully review the records to make certain you provide at the very least every piece of documentation requested, Barry says. Also check to make sure that the photocopies you submit are legible, and include a good cover letter.

4. Write a summary cover letter when you get an ADR or edit to help paint the picture of why your patient belongs in hospice care, Michal says. Don'tjust submit charts.

Mistake: "I've seen everything from no summary letter to those that include too much," Barry says. Your cover letter should discuss what the LCD requires and show how all conditions were met. See the sidebar below for Barry's tips on writing a good cover letter.