Meticulous Documentation a Hospice’s Best Defense in HIS Audit Appeals

Hospices that are meticulous and vigilant with documentation see the best results when appealing payment cuts associated with Hospice Item Set (HIS) audits.

The U.S. Centers for Medicare & Medicaid Services (CMS) developed HIS as a tool to gauge a patient’s overall care experience. The agency requires hospices to submit HIS data for each patient served. Those who do not report those data risk a payment cut of 2% across the board.

Hospices have the option to appeal those 2% reductions, and effective documentation has been a key to success in recouping those funds, according to Bryan Nowicki and Jacob Harris, hospice attorneys at the law firm Husch Blackwell.

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“The hospices that have had success in HIS appeals have maintained meticulous ‘as-they-happen’ documentation of the circumstances relating to or resulting in non-compliance,” Harris and Nowicki told Hospice News in an email. “These ‘paper trails’ have provided critical information around which we have been able to build appeal arguments.”

The HIS is a set of quality measures that assess providers based on factors such as consistency of care with patient treatment preferences, beliefs and values, as well as areas like pain and symptom screening and management.

CMS plans to update its quality reporting requirements in the coming years with new methodologies, but for now HIS remains in place, along with the potential 2% penalty. The agency plans to implement the Hospice Care Index (HCI) and the Hospice Outcomes & Patient Evaluation (HOPE) tool, which is currently in its first stage of pilot testing. When complete, these will replace the current HIS quality reporting system.

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Some hospices encounter circumstances that have contributed to errors or incomplete data reports.

For example, the ways CMS has previously communicated HIS guidelines has led to some of the compliance challenges hospices have encountered, according to Nowicki and Harris.

“Hospices face a number of challenges that hinder their ability to meet CMS’s HIS quality reporting requirements,” Nowicki and Harris wrote to Hospice News. “Hospices have continued to deal with inconsistent communications or direction provided by CMS, [electronic medical record] issues or glitches that affect reporting, and complications affecting whether and how newer providers are able to report information.”

Workforce shortages worsened during the pandemic, which created another compliance hurdle for hospices, according to Harris and Nowicki. Some hospices have been so understaffed that it “significantly challenged” their ability to respond and prepare for regulatory auditing, they added.

When it comes to filing an appeal, time is of the essence, Nowicki and Harris explained.

Hospices that have not met the 90% of all patient HIS reporting threshold receive notices of non-compliance each July. The notice will designate a date in August by which a hospice must file the appeal if it wishes to do so, and CMS will render a decision during September.

If CMS rejects the appeal, hospices have further recourse. They can request a review by the Provider Reimbursement Review Board (PRRB) within six months. This process can take well over a year to complete.

If a hospice’s appeal is unsuccessful, they will see the 2% beginning on Oct. 1 of the year CMS issued the non-compliance notice.

This means hospices must move quickly to take action and should work to avoid documentation issues that could slow them down, according to Harris and Nowicki. For the best chance at success, providers must ensure their documentation is complete, accurate and timely.

“These hospices have also been very diligent in monitoring their compliance throughout the calendar year, so that they have immediate notice of any problems with their reporting, or they can anticipate if problems will arise,” Harris and Nowicki told Hospice News. “Such ‘real-time’ vigilance provides additional options to hospices to try to preempt the need for an appeal, by seeking reporting extensions or exemptions immediately, rather than waiting to raise those issues after the hospice has received a notice of non-compliance.”

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