This transcript has been auto generated
00;00;05;01 - 00;00;26;05
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. Controlling the Narrative: A New Tactic for Auditors and ALJs. Bryan, that's a great title because we're talking about physician narratives. So how quippy of you.
00;00;26;18 - 00;00;41;08
Bryan Nowicki
I try every time I try to make these titles punchy. You got to get those the downloads in the. Not the views what are they the listens the downloads for the podcast? Clickbait. I got a career in click bait. If this attorney thing doesn't work.
00;00;41;08 - 00;01;23;17
Meg Pekarske
Out in this really niche like area but we won't let your head get too big. So we're talking narratives and certification. So the two most common, I think denials are not maybe new to people, but are worth because they're so persistent. Worth talking about some new developments and documentation issues around them. So one is they're saying the medical record doesn't support a six month prognosis and then getting a sort of technical denial on the physician narrative where it's saying the narrative is insufficient.
00;01;23;17 - 00;01;36;14
Meg Pekarske
Like we have had cases where they said the patient is eligible, but the physician narrative is insufficient. I mean, that's a little bit more rare, but it does happen. But what's the new stuff you wanted to share here, Bryan?
00;01;36;14 - 00;02;05;01
Bryan Nowicki
We had the typical version of this narrative sufficiency we've been able to address and be successful by pointing out the regulations that say, you know, judge or auditor, you might be expecting too much of these narratives. They've got to be brief. They got to reflect the patient's clinical circumstances, and they can include checkboxes. Other than that, you know, it's pretty pretty much up to the physician the new twist on this that we have begun to see.
00;02;05;04 - 00;02;30;02
Meg Pekarske
And, Bryan, maybe just to like put the zinger in here when they created the rule and they at the end of the rule, they have to say, like, how much, you know, should this cost you to implement this whole this should take less than 5 minutes or whatever is in the actual rule, which is something we use to get at what the brevity is because.
00;02;30;06 - 00;02;45;19
Meg Pekarske
Right. You have to review the documentation, prepare it. And they're saying this should take 5 minutes. Right. You know, to say that that there should be, you know, paragraphs and paragraphs or, you know, whatever they're looking for. But anyway, just to
00;02;46;12 - 00;02;46;20
Bryan Nowicki
No, and
00;02;46;21 - 00;02;47;17
Meg Pekarske
add color.
00;02;47;23 - 00;03;12;09
Bryan Nowicki
And I think that's important because I think this new twist is kind of taking the position of the government into the direction of requiring more and more and more that really stretches the regulations. And CMS is intent really beyond to an absurd level. So the new twist is we have auditors focusing on the word explanation that is included in the regulation.
00;03;12;09 - 00;03;41;01
Bryan Nowicki
It's called a narrative explanation. And then for the third and later benefit periods, there's a reference to the narrative must include an explanation as to how the clinical findings from the face to face support, a terminal terminal prognosis. And so what we've seen is really a demand that you don't just kind of identify a series of clinical factors and even note increasing weakness as fast score decreased.
00;03;41;17 - 00;04;07;00
Bryan Nowicki
But apparently they think that there should also be a section of the narrative that includes more of an explanation, exactly what they're looking for. I don't know. And whether they're thinking this is a sentence or paragraph after paragraph also unclear. I don't think it's a really a standard that they can define very well. And I don't think it's a standard that appears in the regulations.
00;04;07;26 - 00;04;41;20
Meg Pekarske
It becomes subjective. Bryan I mean, it's like, but this isn't enough and it's like, but I am the actor and you're saying asking me what is in, in my head, thinking about why I think this person is eligible. I mean, to then have a third party say, but that's not what was in your head or like that's not I don't know, it just it gets very sort of entwined and circular and I don't know why, you know, you're going to deny a claim on a technical issue for narrative.
00;04;41;20 - 00;04;42;29
Meg Pekarske
I mean, it just seems.
00;04;43;05 - 00;05;07;14
Bryan Nowicki
Yeah, and I think to a lot of us who have a lot of experience in the hospice space, when you start describing a lot of those clinical conditions and how they've evolved and changed over time, the explanation is self-evident. That is, the explanation is why is this patient ineligible for hospice? Well, they're fast went from a 78 to a 70 and there is doubt.
00;05;07;15 - 00;05;08;05
Meg Pekarske
Yeah. Yeah.
00;05;08;06 - 00;05;45;01
Bryan Nowicki
What do you mean, explanation of this? This is the explanation. But, you know, we wanted to raise it in this podcast because I think it is it's a new way of trying to look at the regulatory language to increase the burden on hospices. So not only do you need to have the clinical findings, but you need to have this separate explanation as if those clinical findings were not explanation enough, we have encountered some male JS who appear to be buying into this because they will kind of go with that argument.
00;05;45;01 - 00;06;05;04
Bryan Nowicki
I think there's some language in the regulations or the cruel commentary about the physician really needs to justify why the patient is eligible. And so they lay out all these new words as if these are now new requirements for a narrative. Well, now it needs to justify, it needs to explain in ways that hospices really haven't ever been doing.
00;06;05;04 - 00;06;29;05
Bryan Nowicki
I think for the reasons you and I described, it's, you know, the mind reader problem, the self-evident nature of this. So it remains unclear what the expectations are from these auditors. And I think to your point, Meg, what is the standard? I don't think they could define a standard or at least they haven't defined one yet about what is an appropriate explanation.
00;06;29;29 - 00;07;04;27
Bryan Nowicki
There may be language to include in a narrative that can be preemptive of this kind of argument and just to make make some sort of, you know, further explanation in a narrative. I'm not saying this is required by the regulations. It's kind of like playing the auditors game. You want an explanation? Okay, well, we'll add something. And if you want it to include something in a narrative along the lines of the face to face, the clinical findings of the face to face encounter, support this patient six month prognosis because dot, dot, dot.
00;07;05;10 - 00;07;34;26
Bryan Nowicki
And maybe having that kind of a sentence as a prompt for a physician to complete with a clause or a sentence or two, at least you can then point back to that and say there is an explanation. Again, I think we still have sound arguments about, you know, the data is the explanation, but just to try to get out, get out in front of what these auditors and a few ALJ are deciding, that might be a good, proactive steps you can take.
00;07;35;07 - 00;08;00;10
Meg Pekarske
Well, and, you know, not letting your foot off the gas in terms of expectation setting with physicians about, you know, this is like one of the most important pieces of documentation in the medical record. It's going to be exhibit one, you know, and if this isn't stellar, like, it makes it a steeper climb for the rest of it.
00;08;00;10 - 00;08;36;24
Meg Pekarske
So I just I think the larger conversation we've had on this podcast about higher physicians who want to do this job well, you know, that aren't just looking for, you know, some extra money, but are committed to this area and committed to what's expected and standards of care and stuff because the days are long past. But, you know, we're doing great work and great services and but none of this other you know, I mean, it's like, yes, all of that stuff matters, but you don't want to have to argue about it.
00;08;36;24 - 00;08;57;15
Meg Pekarske
Right. There is a great compliance officer that I worked with who I said, you don't want to be in the middle of the road. It's not that you're not right like, but who wants to have to argue about it like Bryan? Who wants to go to federal court, you know, to to prove your point. It's like trying to make it as most self evident as you can.
00;08;57;17 - 00;09;18;12
Bryan Nowicki
Well, right. I mean, we, you know, we can win some of these arguments, but you don't want to have to be in a position to win an argument. You want to avoid the argument at the outset. And that's kind of what this suggested language may help you do. And there's a lot of ways you can take similar steps in other areas that we've talked about through these podcasts and when we talk with clients.
00;09;18;12 - 00;09;26;17
Bryan Nowicki
So yeah, better to avoid the battle and get paid than to stand on principle and have to spend a lot of money to fight for it.
00;09;27;12 - 00;09;54;11
Meg Pekarske
Yeah. And I mean, I think that physicians are so used to doing electronic charting and writing notes. And so, you know, it's not like you're asking them to push a boulder up a mountain. I mean, but but I also think maybe the last thing to end on and I think it's a theme throughout a lot of our our podcasts when we talk about audit preparedness is understanding the context like here this is painting the context.
00;09;54;11 - 00;10;23;23
Meg Pekarske
But for the auditor because they're never going to see this patient, all they're going to look at is these documents in isolation and sort of everything needs to be stand on its own, but also for the actor as the physician, they need to understand the perspective of who are they documenting for and that sort of role. One, when we do documented documentation, training is getting people to understand who they're documenting for, which is not themselves.
00;10;23;23 - 00;10;49;09
Meg Pekarske
It's not, you know, I would say not even a clinician always. Right. I mean, it is to someone who really has very little knowledge. And so I think continuing to build that context and perspective, I think helps people document better. It's like what the kind of conversation you would have with another doctor about a patient is totally different than how you are.
00;10;49;09 - 00;11;09;21
Meg Pekarske
Should be different than the bedside manner. You would have to explain someone's medical condition to that like a lay person. And that's sort of what this says, you know, explaining to a person, you know, why this person is eligible for hospice. So but anyway, so. Oh, it's never ending, right? It's never. I know.
00;11;10;04 - 00;11;17;14
Bryan Nowicki
I know. Keeps us busy. But it can be frustrating sometimes. And we feel for the hospices that have to go through it, but we are here to help.
00;11;17;19 - 00;11;22;23
Meg Pekarske
To no end, Bryan. So, but anyway, all right, well, until next time, Bryan.
00;11;22;23 - 00;11;24;03
Bryan Nowicki
Great. Thank you, Meg.
00;11;24;04 - 00;11;30;27
Meg Pekarske
Bye bye.
00;11;30;27 - 00;11;31;20
Bryan Nowicki
Bye bye.
00;11;31;20 - 00;11;47;12
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.