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Standing Up to Scrutiny From Auditors, Payers and Politicians


Fraud and abuse can lead to audits and scrutiny. A panel of industry experts including legal, public policy and financial experts spoke on how providers can prepare for a successful future at the 2024 ̲app, Growth, Innovation and Leadership Experience (AGILE).

Fred Bentley, Managing Director at Medicare Innovation ATI Advisory, moderated the session with panelists Lanchi Bombalier, Healthcare Partner and Hiring Partner at Arnal Golden Gregory LLP; Alisa Gerke, Executive Director at Unity Hospice and Palliative Care; Joy Cameron, Assistant Vice President, Public Policy at Humana; and Shradha Aiyer, Vice President of Product Development and Engineering at ̲app.

The panel discussed scrutiny and audits, regulatory challenges, best practices to achieve compliance and financial sustainability, and the impact of Medicare Advantage plans and payers.

Scrutiny and Audits

Hospice has seen an increase in scrutiny and audits. Bombalier said that article headlines are driving the increase because the government picks up on the articles when they look at initiatives.

“With hospice, it is really about human nature in terms of what we are drawn towards and what we read about,” Bombalier said. “People love to hear success stories. They love to hear horror stories. Around 2022, California sent out an auditor’s report… It was talking about fraud in the hospice industry. And they had headlines like, ‘We identified a building, a single building, in LA County that had 150 hospices located in that building, much bigger than what the building can hold.’ And those types of things get a lot of interest from readers in the industry.”

Gerke’s organization is under a Targeted Probe and Educate (TPE) review and a Consumer Price Index (CPI) audit with six additional documentation requests.

“So it’s not the if; it’s the when,” said Gerke. “[We have been advised] to expect moving through all the different levels of reconsideration, redetermination all the way, pushing through an [administrative law judge].”

Regulatory Challenges

Cameron, who works in public policy, discussed how she sees the regulatory environment changing.

“I always look back at the rate and rule that comes out from our friends at CMS [Centers for Medicare and Medicaid Services] every year,” said Cameron. “In 2030, our debt service as a country will match our Medicare and Medicaid spend. We’ve kind of run up our credit card bills and there’s going to be [fewer] dollars for things like healthcare.”

Cameron is concerned that the amount of debt we owe will increase by 2030.

Aiyer talked about how technology can help providers navigate the changes. She explained that when providers are in the middle of an audit, they should look at how easy it is to pull data so they can validate the actions their staff took leading up to the events. Providers should also be aware of all events and consolidate the data.

“How restrictive can your software be so that that audit process is also being laid out like breadcrumbs?” said Aiyer. “Because there is an algorithm that most of these auditors are following.”

Medicare Advantage Plans

Medicare Advantage plans and the interaction between providers and payers are intensifying. Cameron explained how Medicare Advantage plans are evaluating and assessing care at home providers.

“I think there [is] a myriad of factors,” said Cameron. “How’s your technology going to be a key component? Does your technology talk to our technology? How are you working with care teams that exist within payers? What is the geographic coverage that you have? What’s your ability to outreach?”

Cameron explained that you must have the conversation about whether there is an openness and welcome to things like value-based care risk.

“We need to think about the partnerships we want to build,” she said. “And that we want to build with quality players and providers.”

With more than 350 attendees, more than 50 sponsors and countless connections made, AGILE 2024 was a massive success for everyone. .

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