When to Use a Lawyer vs. a Consultant in a Hospice TPE Audit

✅ When to Use a Hospice Consultant

For most hospices, a consultant is the first line of support during a TPE audit. Consultants bring specialized expertise in hospice documentation, compliance, and CMS audit processes.

You should engage a consultant when you need help with:

• Responding to Additional Documentation Requests (ADRs): Consultants help gather, review, and organize records to ensure submissions are complete and defensible.
• Internal Chart Reviews: Consultants can spot documentation weaknesses before they become denial reasons.
• Staff Education: Training clinicians and IDG members on comparative documentation, eligibility, and timely certifications.
• Corrective Action After Education Calls: Consultants guide your hospice in implementing changes the MAC recommends after each round of review.
• Mock Audits: Preparing your team before an actual round begins.

In short, consultants help you avoid errors, prevent denials, and correct issues early—before they escalate.

⚖️ When to Involve a Lawyer

Legal counsel is usually not necessary for standard TPE reviews, since the program is educational in nature. However, there are situations where an attorney becomes essential.

Consider bringing in a lawyer if:

• You’ve completed three rounds of TPE without improvement. At this point, referral to a UPIC, RAC, or other CMS audit contractor may occur.
• Extrapolation is applied. If denials are extrapolated across hundreds of claims, the financial exposure may be significant.
• CMS threatens sanctions. This may include termination from the Medicare program or civil monetary penalties.
• Appeals are required. Legal representation is often necessary if you move into the formal appeal process (redetermination, reconsideration, ALJ hearing, etc.).

Attorneys are best suited for legal defense and protecting your hospice from financial or regulatory risk once the process has moved beyond education.

For most hospices, consultants are the right choice during TPE rounds, when the focus is on documentation, compliance, and staff training. A lawyer becomes necessary only if the process escalates into referrals, extrapolated repayments, or appeals.

The best strategy? Start with a consultant to build defensible documentation and strengthen compliance. That way, you reduce the likelihood of needing legal defense later.