Hospice care is intended to help terminally ill beneficiaries continue living with minimal disruptions and to provide support for a beneficiary’s family and caregivers. In a recent report, the Department of Health and Human Services Office of Inspector General (OIG) found that hospices are not always meeting two key coverage requirements for the Medicare hospice benefit: (1) that beneficiaries sign an election statement and (2) that a physician certifies that the beneficiary is terminally ill. The purpose of these requirements is, among other things, to properly inform beneficiaries of the implications of hospice care and to prevent Medicare fraud.

The report analyzed data from hospice general inpatient (GIP) stays in 2012, and found that election statements were flawed in 35 percent of them. The OIG reported that election statements did not always explain (as required) that by electing hospice care a beneficiary is waiving coverage of other Medicare services or that hospice care is palliative rather than curative.

In addition, the report found that physician certifications were inadequate in 14 percent of the 2012 GIP stays that were reviewed. In these instances the physician did not meet certification requirements, such as composing a narrative. In many cases the certifying physician appeared to have little involvement in determining that the beneficiary was appropriate for hospice care.

The OIG stressed the importance of fixing these inadequacies in election statements and physician certifications. “It is essential that hospices provide beneficiaries and their caregivers with accurate and complete information, especially about the palliative nature of hospice care and the benefits that they are waiving,” the OIG stated. “These certifications are a critical safeguard in ensuring that beneficiaries are appropriately receiving hospice care.”

The OIG made a number of recommendations to help improve election statements and physician certification processes. The OIG recommended that CMS:

  • develop and distribute model text for election statements;
  • direct surveyors to strengthen their review of election statements and certifications of terminal illness;
  • educate hospices about election statements and certifications of terminal illness; and
  • provide guidance to hospices regarding the effects on beneficiaries when they revoke their election and when they are discharged from hospice care.

In light of the recent OIG report as well as heightened scrutiny and audits, now is the time for hospice providers to take a closer look at their hospice admission practices and procedures with counsel to ensure that they are in compliance with applicable regulations.