The auditing environment has heated up in the hospice industry, with inconsistencies reportedly proliferating among the various types of regulatory enforcement activity — particularly those performed by Medicare Administrative Contractors (MACs). The issue has some hospice providers delving deeper into a range of compliance strategies.

Differences exist in the scope of data being reviewed by MAC auditors, as well as the audit appeals approval and denial processes, said Ashley Arnold, senior vice president of quality at St. Croix Hospice. The Minnesota-headquartered hospice provides care across 85 locations in 10 Midwestern states and has an average daily census of roughly 5,200 patients.

St. Croix Hospice works with three different MAC auditing entities. Variations in auditing methodologies can make compliance a challenging feat for hospices, Arnold said during a recent Hospice News webinar.

“There is no consistency between MACs. What one MAC looks at versus what another MAC looks at can be very different,” Arnold told Hospice News during the webinar. “From a provider perspective, that’s hard to manage, because you are trying to do it right and trying to do what they ask of you, but the expectations can be different depending on which MAC. Being a company that works with all three, I see it all the time in my experience. That’s an area where I think they have an opportunity for improvement is having more consistency in what is being looked at so us as providers can make sure we’re meeting that need.”

Hospices in recent years have seen a plethora of auditing types picking up steam in frequency, including MACs, Targeted Probe and Education (TPE), Supplemental Medical Review Contractors (SMRC), Unified Program Integrity Contractors (UPIC) and Recovery Audit Contractors (RAC). A main purpose of most audit types is to identify hospice providers with frequent errors on their billing claims or other activity that the U.S. Centers for Medicare & Medicaid Services (CMS) considers to be unusual.

Nearly 53% of hospices reported undergoing multiple audits simultaneously within a six-month period during the last year, according to a survey of providers nationwide from four of the largest industry organizations.

MAC audits are among the most challenging, common and complex types of enforcement activity, according to Diana Franchito, president and CEO of HopeHealth. Based in Providence, Rhode Island, the nonprofit provides hospice, palliative care, grief support and dementia services in Massachusetts and in its home state. HopeHealth has an average daily hospice census of about 800 patients, with a similar range for palliative patient volumes.

MAC audits can be spurred by a range of concerns related to outliers in billing patterns, and hospices need to provide staff with a wide lens of education into their compliance risks, Franchitto stated. For instance, lengths of stay for general inpatient level of care (GIP) lasting longer than seven days are a common focal point for MAC audits, she said.

“The dollar amount that could be at stake is significant. At the GIP level, it’s really important for us to make sure we’ve got it all ticked and tied,” she said during the Hospice News webinar. “It’s a very complex process, and establishing a really solid infrastructure is critical in order to deal with these audits. It is really important we are very vigilant in that regard.”

MAC audits take a variety of different claims data into account, but not enough focus is given to hospices’ discharge rates or to providers offering “virtually no GIP levels of care,” Franchitto added.

Staff need to be well-versed in the common GIP clinical and technical documentation errors is a crucial part of ensuring compliance, she stated. Having both internal and external audit review processes is key to developing a strong compliance strategy. This can involve engaging in legal counsel alongside ongoing education among interdisciplinary and back-office billing staff, particularly as clinical and technical documentation errors serve as the most common regulatory red flags, Franchitto said.

HopeHealth’s strategy has relied on greater collaboration among compliance teams and clinical staff, which has allowed for improved understanding of regulatory changes and how they impact care delivery, Franchitto stated.

“Members of our quality and compliance team on a very regular basis go to the interdisciplinary meetings and share with staff what’s new on the audit front and also the results of our internal audits,” she told Hospice News. “It’s kind of socializing staff to the audit world and really helping the team members understand not only what the internal audits found, but also [ways] to get beyond this.”

Navigating through the different auditing processes has become the norm of doing business in the hospice industry in today’s regulatory environment, according to Arnold. But ensuring that staff are sufficiently trained in compliance can mean pouring financial and operational resources into ongoing education and potentially taxing the workforce in the process, she indicated.

Compliance education can be expensive, time consuming and resource-intensive, but the return on investment for hospice leaders is having a clinical team that is fully prepared for audits at any given moment, Arnold stated.

Training staff on sound documentation practices is among the most important areas to address, as clinical and technical errors are frequently flagged in MAC audits, she added. Clinical documentation should adequately capture declines in a patient condition in clearly understandable language.

“We’re not going to see a real reprieve from the audits that are ongoing,” Arnold said. “So, really having a strong process of how you’re going to work through that difficult time of change is going to be important and something that I think a lot of us have in our mind of how that’s going to look moving forward. There’s a lot of unknown. [It] takes just a lot of education and a lot of monitoring internally to make sure that you feel really prepared for any of those audits that are coming.”