This transcript has been auto generated
00;00;05;01 - 00;00;32;07
Meg Pekarske
Hello and welcome to Hospice Insights: The Law and Beyond where we connect you to what matters in the ever changing world of hospice and palliative care. Upping the Ante: Will CMS’s Enhanced Oversight Efforts Cause Hospices to Fold? Wow. What a daunting title we put on this, Bryan. This is daunting. I'm frightened. Even like beginning this podcast. Bold. That's serious business.
00;00;32;08 - 00;00;33;18
Meg Pekarske
What are you thinking here, Bryan?
00;00;34;01 - 00;00;53;18
Bryan Nowicki
Well, you know, I love coming up with these titles and, you know, a little bit of a poker reference in there. But I guess it is it is daunting. You know, nobody wants to fold in a poker hand. You're out of the game at that point. But, boy, it just seems the way it seems is proceeding with some of these efforts.
00;00;54;03 - 00;01;18;26
Bryan Nowicki
A lot is on the line. Are these hospices that that are new hospices or that are recently acquired hospices? So I think CMS is approaching that point where they've heard enough about those four states. They've heard enough about what's wrong with hospice from Congress. And they're they're really becoming they're trying to follow through with those people who are essentially their bosses.
00;01;20;00 - 00;01;27;29
Meg Pekarske
So what is this enhanced oversight for for those listening who might not? What's the skinny on that?
00;01;28;27 - 00;02;06;28
Bryan Nowicki
Yeah, well, that's a program CMS created where they're going to focus on four states California, Arizona, Texas, Nevada, and they're going to do a prepayment medical review of certain hospices that could be newly started hospices. Hospices that have been reactivated after being deactivated for a while. Hospices that have recently been acquired. But for some reason they are kind of new to the submit submission of claims under their current ownership or leadership, and they're going to do a medical review.
00;02;06;28 - 00;02;37;17
Bryan Nowicki
And then from that medical review, there can flow consequences, like you get a prepayment review of your claims and based upon how well you do, they can revoke your billing privileges, they could terminate your provider number, bar you from enrollment, put you on the preclusion list, which really relates more to managed care organizations, Medicare Advantage organizations. So a lot of pretty serious consequences can be visited upon hospice.
00;02;38;07 - 00;03;25;12
Meg Pekarske
Well, and we expect this is going to go and I think Samson said so beyond the four states eventually. But you know new providers I think all of them did provider tpy but this is a little bit different and I think it's the consequences are getting really serious. I mean when we've dealt with new provider, TPI just sort of went on and on and, and I mean, I'm not saying it was pleasant, but that and from real life circumstances because we've been dealing with I'm getting revoked now because you looked at a very small sample of claims and I'm now going to revoke your provider number and like, that's everything.
00;03;25;12 - 00;03;46;18
Meg Pekarske
I mean, you have appeal rights, but it's fairly serious. And so I think the difference here is the consequences and the whole number of claims that you're getting a shot at looking before they're they had to court and be like, no, we think this is that abuse the billing privileges.
00;03;46;18 - 00;04;13;16
Bryan Nowicki
So it as far as the claims they're reviewing, it can seem like it's overwhelming or it seems like it's not enough for them to really get a fair picture of how the hospice is performing so they can do a 100% prepayment review. And that's the too much category. They're reviewing everything. They're holding up payment. It can create cash flow issues for a new hospice or recently acquired hospice.
00;04;13;16 - 00;04;30;09
Bryan Nowicki
Just starting out, you know, every single claim in a month is being reviewed and then a fair portion of them being denied. And then you got to get the appeal process going to even get paid. That's on the you know, it seems like too much on the not enough side. You could have a lot of claims being submitted.
00;04;30;09 - 00;04;54;25
Bryan Nowicki
Maybe they'll just sample ten and then maybe a month later they'll sample ten more and they find errors with 812 claims total. Out of all your claims based upon two small samples like that, and then you get a notice that they're revoking your they're terminating your Medicare number, they're revoking your billing privileges based upon such a small sample.
00;04;55;12 - 00;05;13;18
Bryan Nowicki
So they kind of the process itself can be daunting. And then the consequences, even if the process is not that hurtful, you know, just producing records for 20 claims or so. The consequence and far came to be seem to be disproportionate to what they really looked at by that type.
00;05;13;18 - 00;05;50;12
Meg Pekarske
Well, and CMS has real broad authority and we just got done and thankfully we were able to turn things around and prevail on a revocation that came as a result of of this provisional TPI or enhanced oversight. I just don't get the PPO like that is not something that stays with me. That acronym I got adopted out, I always just say provisional TPI or whatever, but we just got done prevailing in one of those.
00;05;50;12 - 00;06;19;07
Meg Pekarske
And I think it was probably in in that the error rate when you think about it isn't really that high. When you compare it to regular TPI, right. For, you know, one back, you can have an error rate of 25% and essentially get off the TPI while the mass I think is taking a pretty hard line and they're expecting really, really good performance right out of the gate.
00;06;19;07 - 00;06;37;12
Meg Pekarske
And, you know, it takes a while to get through the appeal process. So you may already get the termination letter and you're trying to hurry along the appeal process, but it takes a while to get to ALJ, which is where you get the most movement. So it's, it's, it's converging in a lot of things at the same time.
00;06;37;24 - 00;06;46;22
Bryan Nowicki
Yeah. And CMS is certainly more directly involved in the decision making on these kind of p EPO.
00;06;46;22 - 00;06;47;08
Meg Pekarske
C.
00;06;47;09 - 00;06;47;22
Bryan Nowicki
Reviews.
00;06;48;00 - 00;06;49;10
Meg Pekarske
It doesn't rank for you.
00;06;49;22 - 00;07;19;06
Bryan Nowicki
You didn't you didn't track well. Well, there's another no. When you when you want to talk to CMS, you got to call PAG, EOG or something. So there's yet another kind of another acronym for us to try to remember. As I get older and older, it doesn't get any easier to do that. But but yes, CMS is more directly involved both in deciding, well, how much of an error is enough to say we're going to revoke the billing privileges, like you mentioned, with CPAs?
00;07;19;06 - 00;07;44;04
Bryan Nowicki
For some, Max, it's 25%. And the max set that date back as really a different percentage. But the max have some control and the consequences. You go on to another round. In another round at before you really get potential consequences here. I think they're more strict that they're not going to allow they're going to even come down on you with a more modest error rate.
00;07;44;10 - 00;08;07;16
Bryan Nowicki
And they're not going to wait as long as several rounds of a TP It's going to happen quickly. You mentioned that appeal process. Yes, there's an appeal process. But when you appeal, that doesn't stop the revocation from happening. It's kind of like payment suspensions. It's kind of like some of these other real draconian consequences that you can appeal.
00;08;07;16 - 00;08;28;06
Bryan Nowicki
But, you know, the odds are you're not going to win or you're going to have to survive through months of no revenue before you get a hearing in front of an ALJ or some appellate decision. So you really need to when you kind of are in one of these situations, you've got to act quickly in a number of respects.
00;08;28;06 - 00;08;58;03
Bryan Nowicki
First, you get the PPO set of claim reviews. You want to make sure you're submitting a high quality claim. I mean, you got to submit whatever documents are, but you want to make sure you know what what your documentation looks like because there's likely to be a round two and whatever you can do to improve your processes from round one to round two to show you're getting better, you want to do that and hopefully you won't have to appeal a revocation.
00;08;58;03 - 00;09;31;24
Bryan Nowicki
But once you get that revocation notice you'll have like 65 days to seek reconsideration. But you might want to begin some informal advocacy, gather information that shows how your provider looks in a in a more appropriate context than just a review of 20 claims and try some informal advocacy by reaching out to that. That's just I mean, you could try the Mac, you can try CMS to try to try to share that larger context to see if that has any effect on the decision making over.
00;09;31;24 - 00;09;32;18
Bryan Nowicki
It seems.
00;09;32;29 - 00;10;10;09
Meg Pekarske
And I think that this is a painful process and obviously you want to do everything you can to avoid it. But right this is for sure going to happen if you're a new provider or you've had a change of ownership. And so I think how you approach transactions, you know, those listeners who are doing transactions, I mean, due diligence is always important and you know, more I think the focus has been more.
00;10;10;09 - 00;10;46;02
Meg Pekarske
I'm like, oh, well, indemnification. And you know, if I get claims and I that relate to when you own this, I'll go after you. But but I think understanding their audit experience prior to buying them in addition to your like normal diligence, like how good is their documentation but have they been tested because buying a hospice who's never been tested I think is can be challenging because they've never really been, you know, put to the test, so to speak.
00;10;46;02 - 00;11;15;29
Meg Pekarske
And so we talk about this all the time in our audit podcasts like peer review is really helpful and the how you prevailed in those is very helpful. And so when we've dealt with the exact situations we're talking about here, we were able to say, hey, we've been, you know, reviewed by a u-pick or whoever and done really well and that that was helpful for the buyers to know that.
00;11;15;29 - 00;11;55;02
Meg Pekarske
And it it's something they strongly considered and sort of reversed the tide there. But I think another thing that was a bit surprising to us because this is all a new thing, but now we know is and Bryan, you and I have dealt with this numerous times is when you have one legal entity and has multiple provider numbers under that one tax I.D., the government can if you have an overpayment or recoupment, they can take money from that other provider number.
00;11;56;16 - 00;12;32;05
Meg Pekarske
But in this context of revoking billing privileges, they can do that in this context, too. And and if that provider number is completely not even a hospice, but they're using hospice findings to, you know, they can do that. And so I think that that's a real ah, I guess be thoughtful about how you structure your transactions and I think best to have one provider and number one legal entity.
00;12;32;25 - 00;13;01;27
Meg Pekarske
We won't get into all of the structuring considerations because that's sort of another podcast. But I just think people need to be aware because I think in the olden days people kept all of their business lines in one legal entity and that is ideally the way you want to structure things ever. But also for this too, when you're doing acquisitions, you don't want to structure it like that.
00;13;02;08 - 00;13;18;03
Meg Pekarske
But I guess, Bryan, what other things do you think are helpful for people to know in terms of risk mitigation? I mean, obviously, it's it's it's not a secret this is going to happen. But any other sort of words of wisdom as we close up?
00;13;18;26 - 00;13;48;20
Bryan Nowicki
Well, I think when you talk about the acquisitions and the due diligence, one thing that has been of concern to CMS is medical directors who are spread being spread thin among multiple hospices. So if you're in the business or have an interest in acquiring a hospice, take a look at that medical director. Is that medical director somebody who is working for multiple hospices that might raise a red flag to CMS.
00;13;48;20 - 00;14;09;18
Bryan Nowicki
So I don't know that that's something you typically look at is tell me who else your medical director works for. But I think that would be an important thing to find out because that person is really key to a lot of the to the number one reason why claims are getting denied in these reviews. And that is for a lack of support for a terminal prognosis.
00;14;09;21 - 00;14;39;05
Bryan Nowicki
That kind of all goes back to how the medical director is assessing patients, documenting narratives. So I think that's something to look at. And as you mentioned, other audit history. You and I have talked about the silver lining of those reviews prior to being audited is you get tested and you can improve your processes. And that's one of the things there is a regulation that allows EMS to extend these revocations to other provider numbers.
00;14;39;27 - 00;15;15;11
Bryan Nowicki
One of the things they consider is, has that other provider number had success or lack of success in audits that have affected it? So I think looking at the audit history, that'll tell you whether you're buying more risk or you're buying something that eliminates risk because you had a good u-pick result. And so going through the PPO process, if they decide to revoke, maybe you can say, hey, but we just had you reviewed ten claims, we just had 50 claims reviewed and we got an 80%, you know, 90% success rate.
00;15;15;16 - 00;15;19;23
Bryan Nowicki
Yeah, take that into account. That's the kind of thing that might change mindsets. Yeah.
00;15;20;07 - 00;15;40;02
Meg Pekarske
Because diligence shouldn't be like, oh, they got you picked. They must be bad. I don't want to buy them. I don't think most people think that. But, but I actually, for the exact same reason is that it's actually a good thing. Now if they got you pegged then you. Yeah. There was no happy ending there that that's a different story.
00;15;40;02 - 00;16;09;20
Meg Pekarske
But I guess one final note on your medical director thing, right? The government started to change the law to now require medical directors to be reported on your 855. And so the government just doesn't ask for information just because they actually use that. Now they can connect the dots of who our medical director is, that multiple different hospices.
00;16;09;20 - 00;16;34;25
Meg Pekarske
And so even if you don't know who your medical director may be, another medical director for another hospice, the government's going to know that. Now, that has to mean that people are actually reporting what they should. But, you know, once we get through a revalidation cycle, right, you're not reporting your medical director and your 855. It's going to get rejected and they're going to ask you to report that.
00;16;34;25 - 00;17;04;02
Meg Pekarske
And so so I do think that's a really important point, Bryan, of what other hospices they're at, but also what is their history? I mean, we've dealt with some issues with medical directors getting when we filed very got a new medical director and and essentially Medicaid was like, yeah, we don't want to work with this position. So and you know, we looked at their history and didn't see anything.
00;17;04;02 - 00;17;32;19
Meg Pekarske
But clearly the government knew something that we didn't know. So anyway, I think a lot of focus is being paid on that medical director. And so for so many reasons, that role is just so, so important. So anyway, Bryan, well, this was a bit of a downer, but anyway, that's, you know, we do uplifting things and we have to, you know, be the Debbie Downer is too, I guess.
00;17;32;19 - 00;17;45;07
Meg Pekarske
But, you know, when we got involved in this most recent thing, I mean, it was all hands on deck and but we were able to turn things around, which was a really exciting one for our team.
00;17;45;27 - 00;18;07;27
Bryan Nowicki
Yeah. I mean, it's a downer that these are happening and as I say, many times PMS cast a wide net to a fault and they capture a lot of good providers out there. So that certainly is a downer. We know CMS has a job to do. It's it's trying to weed out the bad folks. It catches some good guys.
00;18;08;06 - 00;18;24;22
Bryan Nowicki
But yeah, the happy part of this story is, you know, we helped one of those good guys get out of a jam and there's a pathway to get out of these jams. If you if you kind of have that that quality in mind, if you're kind of dedicated to the hospice mission.
00;18;24;25 - 00;18;27;06
Meg Pekarske
And a great legal team at your side.
00;18;27;07 - 00;18;28;08
Bryan Nowicki
Well, of course, that.
00;18;28;08 - 00;18;54;20
Meg Pekarske
Goes that's all hands on deck, working around the clock to find a solution and find a way to win. So which is what we we do here, though. All right, Bryan. Well, good title. Thanks for the info. I'm glad that that we had to relive this, but it was nice that we were able to share a story that did have a happier ending.
00;18;54;20 - 00;19;02;19
Meg Pekarske
So right sided oddness though. I don't want to end on a positive note, Bryan, so.
00;19;02;29 - 00;19;07;02
Bryan Nowicki
You bet that had the two happier, happier topics to come, so
00;19;07;11 - 00;19;10;09
Meg Pekarske
Yes. Thank you.
00;19;10;15 - 00;19;14;00
Bryan Nowicki
Yep, thanks Meg.
00;19;14;00 - 00;19;31;20
Meg Pekarske
Well, that's it for today's episode of Hospice Insights: The Law and Beyond. Thank you for joining the conversation. To subscribe to our podcast, visit our website at huschblackwell.com or sign up wherever you get your podcasts. Until next time, may the wind be at your back.