Documentation Issues, Live Discharges, Long Lengths of Stay Drawing CMS Scrutiny

Documentation errors and omissions, live discharges and lengths of stay beyond six months are three red flags that could cause regulators to come knocking at a hospice’s door, according to a new report from Optima Healthcare Solutions.

Hospice utilization among Medicare decedents rose to exceed 50% for the first time during 2018, according to the U.S. Centers for Medicare & Medicare Services (CMS). As utilization climbs, so does the amount of dollars CMS spends on hospice care, spurring the agency to step up enforcement in an effort to control costs. Medicare hospice expenditures rise by about $1 billion annually.

The Office of Inspector General (OIG) at the U.S. Department of Health and Human Services late last year issued a report on vulnerabilities in the Medicare hospice program. Based on its findings, OIG recommended that CMS strengthen the survey process and improve oversight to “identify hospices that engage in practices that raise concerns.”


The increased scrutiny could have serious implications for hospices.

“At a minimum, the hospice will not get reimbursed for claims submitted for a patient whose recertification did not support continued eligibility. If hospices have a significant number of long stay patients, it could trigger a regulatory audit or additional documentation requests (ADRs), at which time the hospice will need to justify those patients under their care,” Jonathan Skypek, vice president of Optima’s hospice component, told Hospice News. That’s why it’s so important to have the appropriate documentation in place. This is a key area of vulnerability for hospices.”

Documentation is a key concern. Even if the hospice follows the correct procedures, they could see an adverse regulatory response if those actions are not documented correctly and sufficiently. Common documentation errors include poor narrative statements justifying the six-month terminal prognosis, which is a major factor in recertification denials, Skypek told Hospice News.


A narrative must be specific, illustrating the patient’s condition in detail and explaining why the patient is expected to reach end of life within 6 months.

“Saying that the patient has a ‘poor appetite’ is not enough. The narrative needs to explain exactly what it meant by that statement, with data to back it up—for example, the number of meals consumed per day and how that has progressed over time,” Skypek said. “It comes down to providing evidence to support your claims. Another mistake is copying and pasting language from a previous recertification, which increases the likelihood of errors and can raise red flags with regulators.”

The narrative must also align with the local coverage determination document published by Medicare Administrative Contractor serving the hospice’s region.

Other frequently occurring documentation errors include failure to document face-to-face encounters with the patient, failing to include the appropriate signatures on the documents, or not completing the documentation within timeframes established by CMS, Skypek told Hospice News. Any of these errors could result in denial of the patient’s recertification.

CMS is also turning a sharp eye towards hospices with high rates of live disharges, which can occur for a number of reasons, some of which are outside of the hospice’s control such as the patient electing to resume curative treatment. Sometimes a patient stabilizes while receiving hospice care, not improving, but also not declining within the expected timeframe.

Patients with conditions such as dementia or chronic obstructive pulmonary disease, for example, tend to have an unpredictable disease trajectory leading to longer lengths of stay.

The hospice can request recertification for patients who have not passed away within six months, allowing them to continue receiving hospice beyond that time frame. However, CMS will want justification for continuing the benefit.

“Although there is no legal limit to the number of times a patient may be recertified for the Medicare hospice benefit, it is the responsibility of the certifying physician to determine that the patient is still likely to die within six months, and explain in the narrative why this is the case,” Skypek said. “If decline is minimal, it will become harder and harder to justify a six-month terminal prognosis, and the risk of recertification denial becomes greater.”

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