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Hospices Should Improve Their Election Statements and Certifications of Terminal Illness


Medicare hospice care is intended to help terminally ill beneficiaries continue life with minimal disruptions and to support beneficiaries’ families and other caregivers. Two key requirements of the Medicare hospice benefit are for the beneficiary to sign an election statement and for a physician to certify the beneficiary as terminally ill. Together, the election statement and certification of terminal illness provide critical safeguards to ensure that the beneficiary understands the hospice benefit and that the physician is involved in determining whether the beneficiary is appropriate for hospice care. However, previous OIG work has raised concerns that some election statements used by hospices are misleading and that physicians are sometimes not involved in care planning and may rarely see beneficiaries. Also, OIG has investigated numerous cases in which hospices submitted fraudulent claims for patients who were not appropriate for hospice care. This report assesses both hospice election statements and certifications of terminal illness.


We based this study on a review of hospice election statements and certifications of terminal illness from a stratified random sample of hospice general inpatient (GIP) stays in 2012. Although the election statements and certifications of terminal illness were collected for a previous OIG study that focused on GIP, these documents are for the hospice benefit as a whole and are not specific to any one level of care.


We found that hospice election statements lacked required information or had other vulnerabilities in more than one-third of GIP stays. Notably, they did not always mention-as required-that the beneficiary was waiving coverage of certain Medicare services by electing hospice care or that hospice care is palliative rather than curative. Further, in 14 percent of GIP stays, the physician did not meet requirements-such as composing a narrative-when certifying, and appeared to have limited involvement in determining that the beneficiary was appropriate for hospice care.


The findings in this report make clear that hospices should improve their election statements and ensure that physicians meet requirements when certifying beneficiaries for hospice care. We recommend that CMS (1) develop and disseminate model text for election statements, (2) instruct surveyors to strengthen their review of election statements and certifications of terminal illness, (3) educate hospices about election statements and certifications of terminal illness, and (4) provide guidance to hospices regarding the effects on beneficiaries when they revoke their election and when they are discharged from hospice care. CMS agreed with three of our recommendations and neither concurred nor nonconcurred with our fourth recommendation.

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