United States: Prepare For Actual On-Site Auditor Questions And Requests

The following questions and requests were posed by actual government auditors – Zone Program Integrity Contractors (ZPICs) and Medicaid Integrity Contractors (MICs) – during on-site audits. Consider integrating this tool into your leadership and employee training, and use these questions and requests to test your audit preparedness. While not everyone in your organization will know the answer to each question, you can use this tool to (i) identify the "go to" person for the information and where it is maintained, and (ii) plan for how that information can be assembled and provided to the auditors.

(This list is also available in a PDF / print friendly version for your convenience.)

Category Question(s)
Billing Practices a. Describe how the hospice bills the Medicare or Medicaid program.

  • Identify the employees responsible for billing (current and during the audit period).
  • How often is Medicare/Medicaid billed?
  • What controls are in place to ensure the correct CPT/Revenue code is being billed?
  • How is billing for Medicare/Medicaid (dual) eligible beneficiaries handled? Are there specific billing policies?
Referrals/Admissions a. How does the hospice obtain patients? Describe the referral and marketing process (i.e., service network of hospitals and nursing home, etc.).

b. What types of documentation does the hospice request from referring practitioners or facilities in order to confirm medical appropriateness of admission into the hospice program?

Determining Eligibility of
Hospice Patients
a. What criteria are used to determine beneficiary eligibility for hospice benefits?

  • Does the hospice make use of any generally accepted industry guidelines (such as LCDs) when determining patient eligibility? Name guidelines, such as LCDs, if they are used.
  • Do hospice staff utilize tools such as Palliative Performance Scale (PPS), functional Assessment Staging Test (FAST), New York Heart Association (NYHA) classification, etc.?

b. Who determines if a beneficiary is appropriate for hospice?

c. Who determines if a beneficiary is appropriate for general inpatient or continuous care, how is that determined, and what criteria are applied?

Certifications and
a. If recertification is required, what is the hospice's procedure for recertification of the beneficiaries' hospice benefit?
IDT Review of Patients a. Does the hospice elicit physician participation in the Interdisciplinary Team (IDT) meetings and Plan of Care coordination?

  • Who is required to attend these meetings?

b. Are IDT minutes part of the patient record?

  • If not, where are they housed; can they be provided?
a. If it is determined that a beneficiary no longer needs or wants hospice services what is the discharge process? Describe the discharge and/or revocation process.

  • Where is this documented in the medical record?
  • How long does discharge take once the beneficiary has been identified as ineligible?
  • Who is responsible for documenting this process?

b. What is the percentage of beneficiaries discharged in a given period?

  • Is this monthly, yearly, etc.?

c. What percentage of beneficiaries revoke their hospice benefit?

d. What percentage of beneficiaries pass away while receiving the hospice benefit?

Documentation a. How are patient assessments performed? Is there a standardized method?

  • Who performs and documents these assessments?
  • Is there a supervisory review of these assessments?
  • How often are they performed?

b. Does the hospice make use of Minimum Data Set (MDS) data for recipients who are residents of a nursing facility?

  • Who has access to this information?
  • Is this documentation routinely maintained in the recipients' records?

c. What is the frequency of patient encounters with the Medical Director and/or the Attending Physician or Certified Registered Nurse Practitioner (CRNP)/Physician's Assistant (PA)?

  • How often do Face to Face Visits occur? d. What documents are prepared to record the rendering of service, and how frequently is this documentation created e.g., right after service is rendered, weekly, etc.?

e. How and where are the provider's medical records stored?

  • Electronic Health Records?
  • Company which provides Electronic Health Records

f. What is the frequency for checking weights and/or other vitals? Who acquires and documents vitals?

g. What is the method and frequency of Mid-Arm Circumference (MAC) measurements?

h. What is the frequency of oximetry measurements?

i. Are blood pressure (B/P) measurements records by the arm or wrist cuff?

  • Repeated if out of a specified range?

j. Can hospice staff make changes to medical documentation? Who and how?

Compliance Program a. Describe the hospice's compliance program.

  • Are internal compliance reviews performed? If so, by whom and how often? Is the review followed by a written summary? Can you provide an example?
  • If problems are identified, what type of follow up or corrective action occurs?

b. How does hospice staff receive training about applicable regulations and guidelines? How is hospice staff updated on new or revised regulations or guidelines?

c. Has the hospice ever been subject to a Corporate Integrity Agreement (CIA)? d. Has the hospice ever been subject to an Office of Inspector General (OIG) audit or State audit?

Policies a. Are there written policies and procedures related to clinical assessments and measurements?

b. Are there written policies and procedures related to service documentation?

c. Does hospice staff have access to the hospice's policies and procedures? Where are they kept?

Human Resources
a. What is your employee turnover/retention rate? If specific details are not maintained, is the turnover rate low, medium, or high?

b. Do you check your employees on the OIG Exclusion database? If yes, how often?

c. Do you verify licensure of all credentialed employees and monitor for disciplinary actions by the various Boards?

d. Do you provide in-service training to newly hired employees, current ones, or both?

  • What types of training?
  • Frequency?

e. Provide a profile of your typical hospice staffing levels for daily workload.

  • Do you have staffing quotas or ratios based on patient numbers?
  • What is the average number of nurse managers, LPNs, RNs, or physician-level (MD/DO/ CRNP/PA) providers on hand at a given time?
General Information a. Where do you provide hospice services? What percentage receives services in their residence, nursing home, assisted living facility, hospital, etc.?

b. Does the hospice have contractual arrangements with other providers, or is it owned by a company that also has ownership of other facilities in the area? Is so, describe the arrangement (i.e., nursing homes, rest homes, assisted living, hospitals).

  • Who is the designated liaison between the hospice and the other service providers?
  • How is the payment to the nursing facility handled?

c. How many hospice patients do you typically service in a given month (or year)?

d. Does the organization provide other health related services beside hospice services such as nursing home care? If so, describe.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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