A proposed new requirement in the 2026 proposed hospice rule could lead to “significant” payment clawbacks and claims denials if finalized, according to some stakeholders.

The proposed rule contains a provision that hospices provide a “clearly titled” physician or nurse practitioner face-to-face encounter attestation that must include a signature and dates of signing. This would be separate from the recertification form.

This requirement, should it come to pass, could invite more opportunities for error in the recertification process, which could lead to clawbacks, according to Howard Young, partner at the law firm Morgan Lewis.

“They now want to change it so that [the attestation] has to be more explicit as part of the certification of terminal illness, and has to be correctly titled,” Young told Hospice News. “What I experience with hospice clients that are subject to audit upon audit is that this is now going to be a change that will result in a lot of take backs based on technical error. Because if the certification of terminal illness is deemed to be invalid for any reason, take backs can occur.”

Hospice providers have faced an onslaught of audits in recent years by Medicare Administrative Contractors (MACs). A majority of providers who responded to a 2024 National Alliance for Care at Home survey indicated that they have undergone more than one audit simultaneously. Most commonly, this was a Targeted Probe and Educate (TPE) in conjunction with a Supplemental Medical Review Contractor (SMRC).

About 52.9% reported having multiple audits, each of a different type, within six months of one another, and 31% said they were required to submit the same charts for each of these audits.

About 77% of respondents said that they have been subject to a TPE during the past five years, and 32% said those audits lasted between 18 months and two years.

Many of these audits focus on questions of patient eligibility, with documentation at the heart of the issue. Even if a patient is bonafide eligible for hospice care, contractors can deny claims based on virtually any documentation omissions or errors.

The proposed requirement would also create a need for electronic medical record vendors to redesign aspects of their systems to accommodate a new documentation rule. However, this piece is likely a quick fix.

“We do not anticipate a significant impact or heavy lift to accommodate these changes ahead of the implementation date,” a spokesperson for the technology vendor WellSky told Hospice News in an email.

The National Alliance for Care at Home, the nation’s largest hospice and home health advocacy group, voiced opposition to the proposed attestation requirements in their public comments on the proposed rule. The Alliance likewise contended that the new formatting requirements could lead to potential errors that could impact payment.

“While the Alliance understands the need for a face-to-face requirement for hospice patients in their third benefit period or later, we are concerned about the proposal that the ‘[face-to-face] attestation, its accompanying signature, and the date signed, must be a separate and distinct section of, or an addendum to, the recertification form, and must be clearly titled,’” the Alliance said in its comments. “The current audit environment already places considerable pressure on hospices, and the proposed formatting requirements risks creating inadvertent compliance pitfalls.”