Hospice & Home Health News 2026June26

OIG Report Cites Concerns with Hospice Enrollment Eligibility Costing Medicare $255.1 Million

A report released by the Office of Inspector General (OIG) on June 23 found that Medicare could have saved $255.1 million if Medicare Administrative Contractors (MACs) had stricter eligibility review procedures. The report looked at 100 initial certification period documentation from 2021 for new hospice enrollees who did not have inpatient or emergency room (ER) claims 18 months prior to starting hospice care. Additionally, these sampled enrollees had at least one paid hospice claim in FY2021 and were still alive 180 days after starting hospice care. OIG found that of the 100 certification periods reviewed, 45 did not meet hospice eligibility requirements. First, clinical documentation for 21 did not support the enrollee's 6-month prognosis. Second, of the 100 periods reviewed 24 did not meet eligibility documentation requirements due to missing supporting documentation, missing elements on the election statement, missing certification of terminal illness, missing information on the certification of terminal illness, and missing signatures from physicians or enrollees. Based on this review, OIG determined that the Centers for Medicare and Medicaid Services (CMS) overpaid these claims by $545,499 and extrapolated that estimate across all hospice claims for these patients in FY2021 to total $255.1 million. In the report, OIG recommended that CMS work with the hospice MACs to consider hospice enrollees with no hospital or ER visits 18 months prior to hospice as a high-risk area in their hospice eligibility reviews. They also recommend MACs "possibly develop pre- or postpayment review procedures" for these new hospice enrollees. CMS concurred with OIG's recommendation and will share the report with MACs to incorporate into their risk analysis and work planning to determine whether the risk area identified in this audit report should be prioritized. LeadingAge will work to follow up with members on the outcomes of this report in terms of MAC audits. Hospice members should consider reviewing their own enrollees and determining the potential risk of compliance issues for individuals with no hospitalizations or ER visits in the preceding 18 months before enrollment and were still on hospice service after 180 days.

GAO Argues Hospices Be Paid Per Visit

A new report from the Government Accountability Office (GAO) finds 20% of hospices were paid more for care than other hospices due to lower visits rates. The report also estimates potential savings in a per-visit payment rates for hospice routine home care. Read LeadingAge's full analysis of the report here.

455 Defendants Identified in National Health Care Fraud Takedown

The Office of Inspector General (OIG) joined federal and state law enforcement announced charges against 455 defendants, including 90 doctors and other medical professionals, for health care fraud and opioid abuse schemes. Defendants included individuals connected with fraudulent claims for amniotic wound allografts driven by a kickback scheme for marketers and medical providers. The alleged kickbacks caused the targeting of hospice patients and applying the allografts "without coordination with the patients’ treating physicians." In other cases, the skin allografts where never even applied. LeadingAge made clear in our comments on the FY2027 Hospice Proposed Rule that any Part B spending on skin allografts (which made up more than 50% of all Part B non-hospice spending) should be removed from the Services and Spending Variation Index non-hospice spending measure due to the overwhelming evidence of fraudulent billing. Additionally, a hospice owner and employees were charged in a scheme that attempted to avoid detection by purchasing information from funeral home employees and fraudulently enrolling deceased Medicare beneficiaries. The owner allegedly billed Medicare for a few days of hospice services for these recently-deceased individuals who had not received hospice care and created fake, back-dated medical records claiming that the beneficiaries had been seen by a physician, thereby allegedly seeking to deceive Medicare by reducing his outlier data metrics on live-discharges. This specific case illustrates another point LeadingAge made in our comments on FY2027 Hospice Proposed Rule, that relying on one metric for fraud detection, such as live-discharge rates, and suspending payments based on that factor is not an effective enforcement tactic and could catch well-meaning providers while missing fraudulent actors.