Preparation for Audits for Hospice Care Agency Staff

Like other healthcare providers, hospices routinely undergo audits by various regulatory bodies to ensure compliance with rules and regulations. Hospices can maintain their reputation, avoid penalties, and continue to provide quality care to patients by being audit-ready. Below are some of the types of audits hospices encounter, and steps hospice agencies can take to prepare.

Types of Hospice Audits

Hospice audits may be conducted by the Centers for Medicare and Medicaid Services (CMS) and the Medicare Administrative Contractors (MACs), the Office of the Inspector General (OIG), or by other payers or financial auditors. Types of audits can include:

TPE Audits

MACs conduct Targeted Probe and Education (TPE) audits to review specific claims submitted by healthcare providers, including hospices, for compliance with Medicare regulations. Hospices selected for TPE audits are asked to submit documentation to support the claims under review. The goals of TPE audits include identifying billing errors, educating providers on proper billing practices, and reducing improper payments.

SMRC Audits

Supplemental Medical Review Contractor (SMRC) audits are conducted by CMS contractors to review Medicare claims for compliance with regulations and policies. Hospices may be subject to SMRC audits to determine whether they are providing appropriate and necessary care to patients and billing Medicare accurately. During SMRC audits, contractors review medical records, documentation, and billing practices to identify any discrepancies or potential fraud.

Recovery Audit Contractor (RAC) Audits

CMS contracts with Recovery Audit Contractors (RACs) to perform post-payment reviews to identify overpayments to providers. RACs can review claims as far back as 3 years. Some areas RACs could focus on include inappropriate GIP and Continuous Care payments.

CERT Audits

Comprehensive Error Rate Testing (CERT) audits are conducted by CMS to measure the accuracy of Medicare claims processing. These audits focus on identifying errors in billing and coding practices that result in improper payments. During a CERT audit, a random sample of claims is selected and reviewed to determine if the services provided were medically necessary and billed correctly.

Other Types of Audits

Hospices may also be subject to other types of audits, such as financial audits, MAC audits, or audits by the Office of the Inspector General (OIG).

Understanding Audit Requirements

Hospice organizations cannot be compliant and prepared without first understanding the audit requirements their agency is subject to. Hospice leaders must stay up to date on all applicable regulations and guidelines and implement proper protocols and documentation practices reflecting that knowledge. By understanding specific requirements for audits, as well as areas of focus, hospices can proactively address potential issues. 

Developing Policies and Procedures

Developing—and regularly updating—policies and procedures is a crucial component of audit readiness. These documents should outline the agency’s processes for patient care, documentation, billing, and other key operational areas. Hospices should regularly review and update their policies to reflect changes in regulations and best practices. Well-documented policies and procedures help to demonstrate a hospice’s commitment to compliance and quality care.

Training Staff

Additionally, staff should be trained to ensure consistent application of policies and procedures across the organization. Employees should understand their role in compliance and the importance of accurate documentation and billing practices. Staff should receive regular training on relevant regulations, agency policies, and best practices to ensure that they are equipped to handle audits effectively. By investing in ongoing education and training for staff, hospice organizations can build a culture of accountability and compliance that enhances audit readiness while ultimately improving the quality of patient care.

Maintaining Accurate Documentation

Proper documentation serves as the ultimate record of services provided. Hospices should establish clear guidelines for documentation practices and ensure that staff adhere to these guidelines consistently. All patient interactions, assessments, care plans, and services rendered should be documented in a timely and detailed manner. Tools such as Hospice software can assist with bringing organization and oftentimes even automation to this process.  By prioritizing comprehensive, accurate documentation, hospices can be better prepared for audits.

Conducting Internal Audits

Conducting regular internal audits and mock audits serves as an important strategy for ensuring audit readiness. Internal audits evaluate the agency’s systems, processes, and controls to identify areas of non-compliance. Regularly reviewing and auditing documentation can help identify any discrepancies or areas for improvement, allowing agencies to proactively address issues and target training needs.

Responding to Audits

No organization is perfect, and a hospice agency may need to respond to audit findings. Some best practices for responding to an audit include:

• Respond in a timely manner. Hospices should adhere to time frames established by auditors.
• Designate an audit response team. The team should have access to and familiarity with medical records, as well as clinical and billing expertise.
• Project manage the response. While various team members may contribute to the audit response, hospices should designate a single project manager or point of contact to ensure that the response meets all requirements. The project manager should make sure that audit response team members’ respective deadlines allow enough time for a complete and thorough review of the total package to be submitted to the auditors.
• Keep contact information up to date. Audit notices may arrive as paper mail, and the clock is ticking. Some hospices have multiple locations and may have more than one NPI. Make sure contact information—names, locations—stays up to date with payers

Conclusion

Audit readiness is a critical aspect of ensuring the continued success and reputation of hospice agencies. Correct claims and solid documentation provide the best defense strategy. By developing comprehensive policies and procedures, training staff, maintaining accurate documentation, conducting internal audits, and responding effectively to audit findings, hospices can demonstrate their commitment to compliance and quality care. By taking proactive steps to enhance audit readiness, hospice agencies can position themselves for success in an increasingly regulated healthcare environment.

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3. What are the crucial skills for home health and hospice hiring?
4. Selecting the best caregiver for end-of-life care