This transcript has been auto generated
00;00;05;01 - 00;00;33;15
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. The TPE Carousel ... Around and Around We Go. Absolutely Bryan, around and around we go. I don't know which number of podcasts this is on TPE, but it just it doesn't stop. And now there's been some new developments.
00;00;33;15 - 00;00;42;07
Meg Pekarske
So we wanted to to share what we're seeing from the field. So why don't you kick us off, Bryan? What's the latest and greatest?
00;00;42;14 - 00;01;21;04
Bryan Nowicki
Yeah, well, we've seen that. We've been dealing with TPEs for years. We've seen them focus on different subject matters. And there's a few new flavors of TPE out there that have come up recently. One of them is it identifies itself in the letter as a benefit sharing or beneficiary sharing focus, which is intended, it appears to look at patients who have gone from home health to hospice, sometimes where those home health and hospice providers are kind of have common ownership or control and other times when they do not.
00;01;21;20 - 00;01;44;09
Bryan Nowicki
So perhaps they're looking at know, is there something about that relationship that causes them to question the eligibility of patients, like if they're being referred from the left hand to the right hand of the same organization? Is there some reason to be suspicious of the eligibility or documentation of those patients? That may be what they're going after. So I've seen a few of those.
00;01;44;18 - 00;02;11;03
Meg Pekarske
And but the betting is are not on hospice and home health at the same time. It's just the referral happens. Yeah. And I feel like that's a recycled issue from, you know, how many years ago I feel like that was coming up. But we haven't seen that for for a long time. But yeah, especially weird when you don't have a home how you're the hospice and yeah.
00;02;11;12 - 00;02;36;26
Bryan Nowicki
And now the home health. There's been TPEs in the home health area that have dealt with beneficiary sharing as well. So this could be just them trying to get the other half of the picture. Maybe the focus is really on the home health side and they're just rounding out the story by going after hospices on these kinds of tips because these have been relatively limited as compared with the other kinds of teepees that have been directed at hospices.
00;02;36;26 - 00;03;01;02
Bryan Nowicki
But it's kind of something new on the horizon. That's what they're looking at. It doesn't in our view, doesn't really change the strategy for responded very much. You still want to get medical records in and, you know, do some advocacy as you can to try to get out of this early on. But it is something new that the government is looking into and therefore we should be mindful of it.
00;03;01;11 - 00;03;32;29
Meg Pekarske
Yeah, well, I was going to say that the other one that really cranks me up is which I, I, I don't recall ever seen in all of my years of practice as these post payment is, which are, I think, troubling to me because there is such a long line of post payment audits going on, whether you have the RAC or the you pick or the smirk, you know, these CPI audits, I mean, there is just layers and layers of post payment review going on.
00;03;32;29 - 00;03;51;08
Meg Pekarske
Why the backs need to do post payment is beyond me and really isn't. I feel like in the tenor of sort of what we're supposed to be doing, like education, real time education, getting feedback, you know, all the stuff. But yeah.
00;03;51;08 - 00;04;17;12
Bryan Nowicki
The TPEs they, they move kind of quickly, you know, once you're in around, you'll get your ADR from for some records and then within a relatively short amount of time, you'll see remittance advice pop up that that addressed the decision that that provide the decision on the claim. And then at least, you know, early on in that patient's claim history or relative to the claim at issue whether the Mac sees a problem with it.
00;04;17;19 - 00;04;34;24
Bryan Nowicki
And then, you know, there's the opportunity for real time corrective action maybe not to save that particular claim, but to save the next one or the next one as things go forward. But yeah, with post payment where they would have to go back a bit longer than the more recent claims, you know, what can you do with that?
00;04;35;00 - 00;05;01;11
Bryan Nowicki
You've already submitted the claim, you've already got paid and maybe there are subsequent claims that are out there. So yeah, as far as TPE being geared toward the MAX, educating hospices so they can take corrective action and then kind of review the effect of the education and making sure hospices are improving themselves. The post pay aspect of this really doesn't foster that kind of that kind of reaction from hospices.
00;05;01;19 - 00;05;34;12
Meg Pekarske
So those are, I guess, a couple of the new things that we've been seeing. I think we're still having people experience going to round two or round three. And this is where I think you shouldn't just sit on your hands and just say, okay, I guess I'm moving to round two or three. I mean, it's like looking at has your error rate gone down significantly?
00;05;34;12 - 00;05;58;02
Meg Pekarske
Was your initial error rate really driven by technical issues that have been resolved? And therefore, you know, you can advocate to not have a full 40 picked in round two. Like if things look good getting off of that because the guidance does talk about this should be an efficient use of resources and what they're trying to get at is improved performance.
00;05;58;02 - 00;06;43;02
Meg Pekarske
So if you had an initially fairly high error rate and now you're around and the target write error rate, is it really worth everyone's time and energy to audit you, especially if you when staff on appeal to that well not required to take that into account. I think that is oftentimes considered. So I think maybe that's something sometimes people are leaving on the table of not knowing that there is advocacy that you can take in terms of, you know, asking for your ID to not go to around to based on some type of, like I just said, analysis of what your improvement has been or making the rounds shorter.
00;06;43;02 - 00;06;47;13
Meg Pekarske
And we have been successful and in some instances on that.
00;06;47;22 - 00;07;15;04
Bryan Nowicki
Yeah, I think, I think you hit upon two of the areas that I think are worthwhile to raise with the Mac and try to get some movement on them. And one is that when they're gone, if you're in around two or well, what they should be doing, we believe, is pulling claims that follow the round one education session, because that's how they test whether that education session really took and the hospice improved.
00;07;15;20 - 00;07;48;22
Bryan Nowicki
We've had some Macs in certain teepees. They'll do the round one education and then they will pull a claim that follows that education. But but it is affected by things that happened before the education session. And so you're like forever doomed to get denials because you can't go back in time. So trying to talk with the Mac about making sure let's have the round two requests relate to patients admitted after the round one education.
00;07;49;02 - 00;08;22;18
Bryan Nowicki
That way you get the full impact of the education in the hospice's response to it. The other one is you mentioned appeals. I think it's a good idea to be prompt with your appeals, try to get some of those initial denials overturned through the appeal process. So if you're successful with that in round one, maybe before you go to round two, you can go back to the Mac and say, hey, no, two or three or however many of the initial claim denials were reversed, you ought to readjust the recalculate our error rate.
00;08;23;05 - 00;08;44;25
Bryan Nowicki
So maybe we're below the threshold which is 15, 20 or 25% depending upon your Mac, and try to get them to do it as you said, Meg, this is kind of discretionary with the Macs. They don't they're not required by regulations to accept this advocacy and agree with that. But it's kind of common sense stuff that we would hope the Macs eventually will see.
00;08;45;04 - 00;08;48;19
Bryan Nowicki
It makes sense and it's consistent with TPE to take those approaches.
00;08;49;08 - 00;09;20;03
Meg Pekarske
Yeah. And so I think you're right, Brian. I mean, sitting on this for 120 days, I would not do that. Even though you have 120 days to appeal this, because if you can get some of these overturned and move through the appeal process quickly, that can be, again, give you additional arguments to make about why you shouldn't have to move to an additional round, because sometimes it takes quite a while for the next round to start.
00;09;20;03 - 00;09;48;21
Meg Pekarske
So like sometimes there's back up on getting an education lined up and then whatever it is, 40 days, 45 days or whatever it is that they would start after that. I mean, when you spaced that out, you could be fairly far into the appeal process. If you don't sit on your hands and wait. So this is something that we generally say try to quickly appeal your TPE and have an impact.
00;09;49;12 - 00;10;10;03
Bryan Nowicki
For one of our clients. That's exactly how it happened. It was, I think, a GIP, TPE, and it just took a long time for the Mac to gather together 20 to 40 claims based upon that hospice's utilization. And so we were able to get ALJ decisions before round two would have started and we were very successful at the ALJ stage.
00;10;10;19 - 00;10;33;05
Bryan Nowicki
And the MAC took into account our wins at the ALJ stage in deciding to release them from the round two because they realized their initial error rate was was incorrect, or at least according to an ALJ. And thankfully they took that reasonable approach. It's not going to happen every time. But that was heartening to see a mac react that way.
00;10;33;22 - 00;11;09;20
Meg Pekarske
Yeah, definitely. And and I have found that the Macs are open to listening and because these take a lot of resources on their end to and I think they want to be efficient in how they're using their internal resources. I think one frustrating part that maybe we can end with here is someone reached out earlier this week about being on a continuous care teepee and like they can't find the denial reason.
00;11;09;20 - 00;11;36;26
Meg Pekarske
Right. And it's just very conclusory, like not medically necessary. Well, even from the denial reason, you can't help but why like and they're just down coding it to retain home care. So it's clearly not something with the units, right. Because those units you just get a haircut on, you know, the number of hours. But here it's down code to routine home care and there's just not a lot of information.
00;11;36;26 - 00;12;03;19
Meg Pekarske
And so I think if we're going to call this an education process, education should be I can understand from the decision what you think I'm doing that's incorrect. And that just way to the education that might happen five months from now, because people really do want to take timely action. And I think that that's, you know, in line with the purpose of this.
00;12;03;19 - 00;12;20;01
Meg Pekarske
And so I think it can be hard to get that more detailed information because remittance advice is sometimes just use codes. And even if you go into DDE and look at that, we're finding that there's not much more detail in there.
00;12;20;18 - 00;12;40;07
Bryan Nowicki
Yeah, that's exactly it. Those remits, they're heavy on codes, even codes that are supposed to alert people to appeal deadlines. Well, it's a code. You have to look up the code to figure out that it's actually an appeal alert, but also for the reason for the not for the denial and the codes. I mean, there's there's a limited number of codes.
00;12;40;07 - 00;13;11;10
Bryan Nowicki
So they're necessarily generally stated denials. You look up one code and it says something about, well, there's a problem with your certification. Well, but what there could be, you know, many, many different kinds of issues with the certification and then on the clinical side, you know, just no, not reasonable and necessary. Well, anybody who's been through an audit, a real post pay audit, even the initial auditors are providing some information about their review of the record.
00;13;11;10 - 00;13;36;14
Bryan Nowicki
And it's either the patient was chronic, not terminal, or there's some data about some clinical data that they're basing their opinion on here. You have nothing to go with and you're probably not going to get something to go to react to until you get a redetermination decision, which is like your your third opportunity at advocacy. And really the first one where you're going into it with eyes wide open and knowing what you're up against.
00;13;36;15 - 00;13;46;22
Bryan Nowicki
So yeah, that is a challenge and you kind of have to deal with it by trying to take on as many issues as you can or can reasonably predict are at the heart of the denial.
00;13;46;22 - 00;13;58;14
Meg Pekarske
Reason Yeah, more bad news. Bryan That's just like it's like walk in the room and just watch stuff you like. Yeah, I've learned how.
00;13;58;16 - 00;14;07;07
Bryan Nowicki
Just the cooler. Isn't that somebody they that walks through the casinos and gives everybody bad luck or something? I thought there's a movie about that, so.
00;14;07;10 - 00;14;14;15
Meg Pekarske
I don't know. I don't know. But you would know because you're you're a what do you call people into film.
00;14;14;26 - 00;14;16;01
Bryan Nowicki
A movie buff?
00;14;16;01 - 00;14;18;07
Meg Pekarske
No, no. There's like a fancy word.
00;14;18;07 - 00;14;19;19
Bryan Nowicki
For in a cinephile.
00;14;19;19 - 00;14;20;21
Meg Pekarske
File. Yeah.
00;14;20;22 - 00;14;25;24
Bryan Nowicki
Yes, I yes, I'm a of file.
00;14;25;24 - 00;14;34;00
Meg Pekarske
But yeah, you're on. Whatever. Roger Ebert's favorite movies. Like best movies. What are you on?
00;14;34;07 - 00;14;41;10
Bryan Nowicki
You know, I'm well, it's chronological. I'm trying to run through his five star reviews. I'm up to 1968. So.
00;14;41;10 - 00;14;42;06
Meg Pekarske
All right.
00;14;42;10 - 00;14;51;28
Bryan Nowicki
Better About Years is my next movie. And I had to see a lot of silent films to get there. So at least I'm in color now.
00;14;51;28 - 00;15;27;02
Meg Pekarske
So that's well, I think everyone probably can can see themselves and what we just talked about. But I think that the wrinkle is don't just sit on your hands. I think there are things you can do in terms of advocacy. And I think quick appeals are important. And, you know, reaching out to to us because we can, you know, help you sort of figure out, do you have a case for not moving to another round and how to go about doing that so anyway.
00;15;27;04 - 00;15;28;11
Meg Pekarske
Until next time, Bryan.
00;15;28;18 - 00;15;33;04
Bryan Nowicki
All right. Thanks a lot, Meg.
00;15;33;04 - 00;15;50;25
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.