Hospice & Home Health Audit Attorneys

Know what you’re up against: audit, suspension or revocation

A records request or additional documentation request from a Medicare Administrative Contractor (MAC), a Recovery Audit Contractor (RAC) such as Performant or Cotiviti, or a Unified Program Integrity Contractor (UPIC) such as Qlarant, SafeGuard Services or CoventBridge initiates a claims review and opens your agency to a potential recoupment demand. A payment suspension notice holds Medicare payments, in whole or in part, on reliable information of an overpayment or a credible allegation of fraud, and the rebuttal window is 15 days. The UPIC continues the investigation by reviewing documentation for overpayments. A revocation notice ends the agency’s enrollment on a stated effective date even while it gives the agency an opportunity to appeal the revocation. All three can be under way at once, and the response to one becomes evidence in the others.

Providers facing an audit play defense

You must treat even the first records request as the start of the case. Most reviews begin with a request for a small number of patient charts tied to eligibility, certification or level of care. The scope rarely stays small. Once the first sample is reviewed, contractors widen the date range, add benefit periods and ask for election statements, plans of care, interdisciplinary group notes, visit records and referral-source information. The language used, the documents chosen and the explanations offered in that first response become the foundation for the reviewer’s conclusions, and early mistakes are difficult to undo later.

Hospice and home health claims are defended on the eligibility record of each patient, and the elements reviewers test are specific. Reviewers frequently apply local coverage determinations (LCDs) rigidly rather than evaluating the total clinical picture and attending physician judgment. Before anything leaves the agency, assemble the full record for every requested patient and benefit period and read it the way the reviewer will.

Answer a payment suspension as a business emergency

A suspension is not a finding, it is simply an allegation, but it stops cash flow before anything is investigated or decided. The rebuttal statement has to address the basis stated in the notice, which is often described only in general terms, supply and explain the documentation behind the flagged claims, and describe the controls the agency already has, all within the 15-day window. In parallel, the agency needs a plan for payroll and patient care through a hold that can run 180 days, be extended and, where it rests on a fraud allegation, continue until the investigation is resolved. Suspended providers can also expect a large post-payment records request as part of the investigation which often converges in an overpayment demand.

Fight a revocation on the record CMS actually relied on

Revocations under 42 C.F.R. § 424.535 are issued for 23 enumerated reasons, and the defense must attack the cited problem: a site visit that recorded the location as closed or non-operational, an alleged abuse of billing privileges, a problematic affiliation, or failure to produce documentation. A corrective action plan is necessary where the revocation rests on non-compliance that can be cured; it is not available on other grounds and it is not an appeal. Whether or not a corrective action plan is submitted, a revocation determination must be appealed to CMS with a request for reconsideration. If the revocation is reversed, the re-enrollment bar falls with it; the length of the bar is set by CMS and depends on the ground and the history, and the deadlines stated in the notice letter govern.

Know the deficiencies contractors are looking for

Hospice and home health findings cluster around a predictable set of weaknesses. Knowing which one the contractor is building toward shapes the response, because the record you produce at the request stage is the record you argue from through every level of appeal.

Understand what can and should not be fixed

A well-intentioned effort to “fix” a chart creates a second problem on top of the first, and the second one can create worse problems. Authentication is different from supplementation, and supplementation is different from rewriting history. A certification narrative added late, or a face-to-face attestation signed after the request arrived, will be read as exactly that.

Before changing or adding anything after receipt of the request, determine what the applicable CMS rule actually permits and preserve the original entry. There may be an opportunity to “paper-over” some errors or omissions, but strict rules apply.

Produce exactly what is required, organized so the reviewer can follow it

One common mistake is treating the response as an export: pulling the electronic record, uploading thousands of pages and assuming the reviewer will find the certification narrative and the decline data that matter. The opposite mistake is sending less than what was asked. A defensible claim is denied when the evidence is buried or never tied to the eligibility requirement being tested, and once a record is produced it can be used for any purpose, including new audits and recoupment demands.

Medicare auditors often are not clinicians, and even a clinical reviewer may have no hospice or home health background. Organize the production so that a reader without that background can follow each patient from the eligibility rule to the note that satisfies it.

Control communications and read the signs is the audit will escalate

Designate one point of contact, preferably counsel or a trained compliance leader, and route every communication through that person. Keep a contemporaneous log of every contact: date, participants, topic, documents requested, what was said and any follow-up promised. Medicare investigators, many of them former law enforcement, are trained to elicit explanations, and the attempt to talk a contractor out of an audit is where accusations of misstatement begin.