Hospice providers must always obtain written certification that a patient meets Medicare's hospice coverage criteria. Written certification of terminal illness needs to be obtained no later than 2 days after hospice care is initiated, and must be on file in the hospice patient's record prior to the submission of a claim to the Medicare contractor. Certification must be made by the medical director of the hospice and, if applicable, the patient's attending physician. Payment for hospice care will begin the date certification is obtained.
This initial certification satisfies the hospice certification requirement for the first 90-day period of coverage. Additional periods require recertification, which can be obtained 15 days prior to the next benefit period, but no later than 2 days after that period begins.
Per the Medicare Benefit Policy Manual, the written certification must include:
- A statement that the patient's medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course;
- Specific clinical findings and other documentation supporting a life expectancy of 6 months or less;
- Signature(s) of physician(s), the date signed, and the benefit period that the certification or recertification covers; and
- The physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the forms.
Additionally, if a hospice patient requires a third benefit period, hospice physicians or hospice nurse practitioners must complete and document a face-to-face encounter with the patient prior to that period. The face-to-face encounter must take place no more than 30 days prior to the benefit period, and must be documented by a properly executed attestation form signed by the performing hospice physician or nurse practitioner.
Due to the burdensome nature of this requirement, hospice recertification requirements have increasingly become an area of focus for Recovery Auditors. The Recovery Audit Contractor (RAC) for Region D, HDI, recently added "Face-to-Face Evaluation for Recertification of Hospice Care" as an approved audit issue.
Failure to meet the face-to-face requirement results in the hospice's failure to recertify the patient's terminal illness eligibility, and the patient is then ineligible to receive the benefit. Hospice providers thus must have systems in place to ensure compliance with Medicare's hospice patient recertification requirements. The timing and proper execution of hospice recertification forms will continue to be a changing and essential aspect in obtaining full Medicare reimbursement.
Our firm assists hospice providers in the implementation of hospice compliance plans. We regularly represents hospice providers nationwide in then defense of RAC, Medicare, ZPIC and other audits. If you or your hospice entity have any questions regarding Medicare's face-to-face recertification requirements, or otherwise need assistance, please contact a Wachler & Associates attorney at 248-544-0888.