Navigating the CMS Hospice Audit Appeal Process

As audits proliferate in the hospice space, providers can benefit from understanding the appeals process.

Hospices are increasingly wading through an alphabet soup of auditing activity in the industry. Auditing types anticipated to ramp up in hospice include Targeted Probe and Educate (TPE) audits conducted by Medicare Administrative Contractors (MACS) and others involving Unified Program Integrity Contractors (UPIC), Supplemental Medical Review Contractors (SMRC) and Recovery Audit Contractors (RAC).

In the midst of this activity, providers need to understand their options for appeals, according to Meg Pekarske, partner at the law firm Husch Blackwell. A lack of understanding around different auditing processes can impact hospices on both financial and operational levels, Pekarske said at the National Hospice and Palliative Care Organization’s (NHPCO) Annual Leadership Conference.


“Audits aren’t really just a compliance problem, they’re an organizational problem, and you need help from a lot of different people,” Pekarske said. “[With] all these different contractors [it’s] who they are and how concerned you need to be about them. Because there’s certain things that are very routine, but there’s gonna be other things that are not routine. Really importantly, [it’s] understanding how cash flow is going to be impacted: Is it a ‘now thing,’ or is it a ‘later thing’?”

A key purpose of most audit types is to identify providers with frequent errors on their Medicare claims or other activity that the U.S. Centers for Medicare & Medicaid Services (CMS) considers to be unusual.

Hospices to understand the different layers involved in the appeals process, according to Amanda Tippin, corporate compliance officer at Trustbridge.


The audit appeal process can be “very daunting” for hospices when receiving initial records requests and determining what information is needed to back a billing claim, Tippin said.

“We want to make sure to address each of the appeals successfully,” Tippin said at the NHPCO conference. “It’s trying to digest and extract the boiler points [and] what they’re really getting at – you have to really read and extract those. We usually put them in a summary format kind of page [when] we respond to appeals to pick apart their rationale for denying our claim. The reviewer may have overlooked a key piece. it’s really different for the different types of audits that you get. Some of them are easy to digest. [For] other ones, you need to take the time to pull out all those key elements.”

Strong clinical documentation is a hospices’ greatest weapon in an auditing appeals process, Pekarske indicated. For example, when responding to audits around appropriateness of services received or questions regarding eligibility, hospices should avoid including lengthy clinical summaries, she stated.

Additionally, hospices can benefit from understanding their scope of options when communicating with auditing contractors, she said.

A “changing tide” is occurring when it comes to hospice auditing appeals processes, according to Pekarkse. Among the shifts is that some Medicare contractors allow the ability for hospices to discuss issues flagged before an audit decision is solidified

“Some contractors actually allow you to have a discussion before they file their final audit report. That’s really helpful, because you get an opportunity to influence it,’ Pekarske said. “Many [hospices] found that to be useful if they’re dealing with a SMIRC, RAC or UPIC, you have this opportunity to give additional documents and have a discussion.”

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