A new report from the HHS Office of Inspector General (OIG) is signaling where future hospice eligibility reviews may be headed.
The report examined hospice patients who had no inpatient hospitalizations or emergency department visits during the 18 months before electing hospice. Based on its findings, OIG recommended that CMS work with Medicare Administrative Contractors (MACs) to consider this group a higher risk population for hospice eligibility reviews and explore targeted prepayment or postpayment review processes.
CMS agreed to share the findings with MACs as they determine future audit priorities.
Importantly, the report does not suggest that patients without recent hospital or emergency department visits are ineligible for hospice. National provider organizations, including LeadingAge, cautioned that many patients experience a gradual decline at home without requiring acute care. They emphasized that hospitalization history alone should not be used to determine hospice eligibility.
Instead, the report reinforces the importance of clear clinical documentation that supports terminal prognosis and hospice eligibility, particularly for patients whose decline may be less obvious in the medical record.
Why it matters
As CMS and MACs continue expanding program integrity efforts, this report identifies a potential new area of audit focus. Hospices should expect continued scrutiny of eligibility documentation, especially when patients have limited recent acute care utilization. Strong documentation remains the best defense while ensuring eligible patients continue to receive timely access to hospice services.
What to do