Understanding Today’s Home Health Compliance Challenges

Home health agencies face unprecedented scrutiny through multiple audit types:

  • Targeted Probe and Educate (TPE) Audits: Three failed rounds can fast-track certification loss

  • Recovery Audit Contractor (RAC) Reviews: Focusing on improper payments and length of stays

  • Supplemental Medical Review Contractor (SMRC) Audits: Often triggered by previous audit findings

  • Unified Program Integrity Contractor (UPIC) Reviews: Most comprehensive government scrutiny

  • Medicaid Review Audits: State-specific compliance requirements

Comprehensive Hospice Compliance Services

  • Full Compliance Assessments
  • HIPAA Privacy Risk Analysis
  • Pre-Bill Audits
  • Corrective Action Plan Development and Implementation
  • ADRs
  • Denials and Appeals
  • Audit Assistance for all audits by government contractors
  • Survey Readiness
  • Mock Surveys
  • Expert Witness Testimony
  • Independent Review Organization for Corporate Integrity Agreements
  • Staff Training and Education
  • Quality Measure and Star Rating Improvement
  • Performance Improvement

Medicare & Medicaid Audit Navigation

Understanding TPE Audits

Targeted Probe and Educate (TPE) audits conducted by Medicare Administrative Contractors (MACs) are critical evaluations for new and existing agencies with Medicare billing requirements. This process begins with an additional documentation request for already billed claims.  Three rounds of failure can fast-track the loss of certification and trigger additional audits by the MAC or other government auditors.

Our Recommendation:
Pre-bill audits to ensure your claims meet all requirements before submission. Once billed, corrections are no longer possible. With SimiTree’s expert guidance, you can confidently navigate the TPE process and increase your success rate.

THE AUDIT PROGRESSION

  1. Recovery Audit Contractor (RAC) Audits
  • Focus: Improper payments and billing practices
  • Evaluate: Medical necessity and skilled needs
  1. Supplemental Medical Review Contractor (SMRC) Audits
  • Typically initiated after a poor performance in previous audits.
  1. Unified Program Integrity Contractor (UPIC) Audits
  • The most comprehensive level of review
  • Can examine small or large sample sizes
  • Often requires attorney representation along with billing/documentation review and defense
  • May require a response within just 30 days

Important to Note:

  • Multiple audits often occur simultaneously
  • Some records may be reviewed under different audit types
  • Most common: TPE and SMRC concurrent audits
  • Government error findings can trigger additional agency reviews

These Audits May Require SimiTree Assistance in:

  • ADRs (Additional Documentation Requests)
  • Timely responses to prevent red flags
  • Appeals process navigation if denied
  • ALJ (Administrative Law Judge) hearings – where SimiTree can serve as expert witnesses

Trust in Accredited Experience

Our compliance team members are certified consultants for CHAP (Community Health Accreditation Partners) and ACHC (Accreditation Commission for Health Care), and includes previous surveyors for Joint Commission and CHAP, bringing accreditation-level expertise to every client engagement. This certification and surveyor experience ensures we deliver guidance that not only meets regulatory requirements but also aligns with the highest industry standards for quality care. 

Hospice Compliance Services You Can Access

  • Medicare Hospice Benefit Eligibility: You’ll master accurate patient certification and recertification processes, reducing claim denials.
  • Education and Training: We partner with you to conduct comprehensive mock surveys that mirror actual surveyor visits. Our team evaluates all regulatory requirements, prepares your staff through hands-on training, and provides detailed findings reports. We’ll help you develop, evaluate, and improve your QAPI program to ensure ongoing compliance.
  • Post-Survey Support: Our team guides you through every step of the correction process, from developing a thorough plan of correction to implementing sustainable solutions that address survey findings.
  • Hospice Survey Preparation: You’ll undergo mock surveys and receive guidance on corrective action plans to ensure survey readiness. As your survey focus and team change, we assist you during the transition and educate you on increased scrutiny when CMS shifts focus and changes the accreditation team.
  • Hospice Quality Reporting Program (HQRP) Compliance: Confidently meet CMS quality measures and reporting requirements, avoid penalties, and improve patient care outcomes.
  • Interdisciplinary Group (IDG) Documentation: Maintain comprehensive care planning and coordination records that demonstrate your team’s collaborative approach to patient care.
  • Hospice Item Set (HIS) Management: Ensure accurate and timely HIS submissions while maintaining compliance standards. Our streamlined approach helps prevent penalties and frees your staff to focus on their primary mission – delivering exceptional patient care.
  • Hospice Eligibility Reviews: You’ll receive an expert assessment of your certification and recertification documentation, minimizing eligibility-related risks.
  • Hospice-Focused Audits: You’ll get targeted reviews of high-risk areas, including medical necessity, live discharges, and long lengths of stays, identifying improvement opportunities before surveyors do.
  • Regulatory Change Management: You’ll stay ahead of evolving hospice regulations and payment models, adapting your operations proactively.

Benefits of Choosing SimiTree for Hospice Regulatory & Compliance Solutions:

  • Hospice-Exclusive Insights: You’ll gain insider perspectives on compliance by tapping into knowledge from former hospice executives, clinicians, and surveyors.
  • End-of-Life Care Expertise: You’ll receive guidance that balances regulatory compliance with compassionate care delivery, enhancing your service quality.
  • Proven Strategies: You’ll implement approaches that have helped over 500 hospice agencies improve their compliance, benefiting from tested methodologies.
  • Customized Approach: You’ll receive tailored solutions that fit your hospice’s size and needs, whether you’re a small community provider or a large national organization.

Don’t let compliance concerns distract you from your mission. Partner with SimiTree to enhance your hospice compliance and focus on what matters most – providing dignified, compassionate end-of-life care.

Bundle & Save 

Our hospice compliance and regulatory services naturally complement several other key service areas: 

  • Hospice Mergers & Acquisitions (M&A) 
  • Hospice Billing (RCM) 
  • Hospice Operational Consulting 
  • Hospice Quality Assurance and Performance Improvement (QAPI) 

If you’re considering any of these home care services or our compliance and regulatory offerings, ask about our bundled solutions for comprehensive support and cost savings. 

Frequently Asked Questions