Auditors are raising new questions around two common issues in hospices’ Medicare claims — documentation supporting patient eligibility and the physician narrative.

Program integrity issues and quality concerns have raised the bar of regulatory oversight in recent years, with auditing activity ramping up as more providers undergo multiple audits simultaneously each year. New documentation red flags have cropped up on auditors’ radars that could be complicated hospices’ path to compliance, according to Bryan Nowicki, partner at the law firm Husch Blackwell

Claim denials most frequently occur due to insufficiently documented evidence that demonstrates a patient’s eligibility within the physician narrative explanation, Nowicki stated. Auditors have increasingly required more details to support a patient’s six month terminal illness prognosis, potentially stretching the boundaries of hospice requirements stipulated by the U.S. Centers for Medicare & Medicaid Services (CMS), he indicated.

“The new twist is we have auditors focusing on the word ‘narrative explanation’ that is included in the regulations [on] narrative explanation,” Nowicki said during a recent Husch Blackwell podcast. “We’ve been successful by pointing out the regulations that say the auditor might be expecting too much of these narratives. The new twist is the position of the government in the direction of requiring more and more and more that really stretches the regulations and CMS’ intent beyond to an absurd level.”

Hospice physicians are responsible for determining patient eligibility, prognostication, the level of care they need and determining whether services are related to their terminal condition. CMS’ conditions of payment (COPs) require a hospice physician to write a narrative summary that explains a terminally ill patient’s medical condition and their prognosis of six months or less of life.

A physician’s narrative explanation should include a clinical face-to-face finding that explains the patient’s clinical decline, Nowicki stated. The COPs stipulate that the explanation is a brief statement and confirms the physician’s documented narrative based on the patient’s medical record and assessment. However, auditors have increasingly requested more information to support the physician narrative explanation in addition to the regulatory requirements, according to Nowicki.

This deeper examination has thus far lacked clarified standards around appropriate narrative explanations and has resulted in adding to hospices’ burdens when responding to a growing volume of audits, he stated. Hospice physicians may need to justify why a patient is eligible to receive care in more nuanced ways than they have historically done, Nowicki said.

“What we’ve seen is really a demand that [hospices] don’t just identify a series of clinical factors … but apparently [auditors] think that there should also be a section of the narrative that includes more of an explanation,” Nowicki said. “It remains unclear what the expectations are from these auditors. They haven’t defined a standard about what is an appropriate explanation … and I don’t think it’s a standard that appears in the regulations. It’s a new way of trying to look at the regulatory language to increase the burden on hospices.”

Hospice auditing processes have become more subjective, particularly when it comes to the physician narrative, according to Meg Pekarske, partner at Husch Blackwell. Auditors’ subjectivity has complicated hospices’ ability to navigate documentation compliance successfully, she stated.

A significant part of responding and preparing for audits is helping clinicians to fully understand the context around the physician narrative explanation, Pekarske said. Clinicians need to have both the training and the internal drive to document patient conditions according to standards. Physicians need to be able to paint a picture of the patient’s medical condition for auditors in concise layman’s terms, a feat not always easy to achieve, she indicated.

“[It’s] not letting your foot off the gas in terms of expectation setting with physicians about one of the most important pieces of documentation in the medical record,” Pekarske said during the podcast. “It’s going to be exhibit one. If it isn’t stellar, it makes it a steeper climb for the rest of it. It’s trying to make it as self-evident as you can [and] painting the context for the auditor. For the physician, they need to understand the perspective of who they are documenting for. Continuing to build that context and perspective helps people document better.”