New Hospice Enrollees Without Recent Hospital Claims: What the Paid Claims Were Missing

The OIG new hospice enrollee eligibility audit found unsupported terminal prognoses and missing eligibility documents behind paid Medicare claims in a selected patient group. For the nurse, medical director or biller who sees admission decisions from inside a hospice, the question reaches beyond the claim history: what did the patient file show when the hospice billed Medicare?

In its June 2026 report, the Department of Health and Human Services’ Office of Inspector General found that documentation for 45 of 100 sampled initial certification periods failed Medicare hospice requirements. Hospices had billed Medicare for patients whose files lacked the clinical support or paperwork needed to justify payment. Taxpayers paid for those gaps. That distinction matters in hospice fraud investigations: a review of the patient’s condition and a review of the election paperwork answer different questions.

What No Recent Hospital Claims Means in the OIG Audit

The OIG audit of new hospice enrollees with no hospital visit claims used a combined claims-history and survival screen. Its sampling method selected initial certification periods for people who met all of these conditions:

• No hospice claim in the 12 months before starting hospice care in the audit period.
• No inpatient or emergency-room claim in the preceding 18 months.
• At least one paid hospice claim in fiscal year 2021.
• Still alive 180 days after hospice care began.

The inspector general started from the expectation that declining health would often produce an emergency-room visit or inpatient stay before hospice. It examined the group whose claims lacked that history.

The claims screen selected the files. The eligibility review examined the prognosis and the documents supporting the election and certification.

Who Determines Eligibility for Hospice?

For the initial benefit period, the hospice medical director or physician member of its interdisciplinary team certifies terminal illness, along with the attending physician if the patient has one. Medicare requires Part A entitlement and a prognosis of six months or less if the illness runs its normal course.

The clinical information supporting that prognosis belongs in the medical record with the written certification. A signed hospice election records the patient’s choice and understanding of hospice care. These are the requirements the inspector general tested when it reviewed the selected files, and they are central to examining unsupported admissions and recertifications.

What Happens If a Hospice Patient Lives Longer Than Six Months?

A patient can continue receiving hospice care when the required recertifications support continued eligibility. The benefit provides two 90-day periods followed by an unlimited number of 60-day periods for eligible patients.

Survival supplied a retrospective selection condition in this audit. The reviewers went back to the initial certification period to examine what the records supported at admission.

What the Inspector General Actually Sampled

The inspector general sampled initial 90-day certification periods, each covering the start of hospice care. Its selected population contained 46,767 such periods, with 125,329 paid claims and $580.5 million in Medicare payments for fiscal year 2021.

The random sample represented 100 enrollees and included 260 claims totaling $1.2 million. Hospices bill monthly, so a single initial period could contribute several claims.

The inspector general obtained claims data from the Centers for Medicare & Medicaid Services and requested the medical records from the hospices. An independent medical review contractor examined whether the care was medically necessary and whether the records met the eligibility documentation requirements. The claims screen identified the population. Medical-record review produced the findings.

The Findings Split Between Clinical Support and Missing Documents

The audit identified distinct failures in the files supporting the paid claims. Its findings show why the distinction matters to someone who handled the admission or billing.

Clinical Support for Terminal Illness

For 21 initial certification periods, the independent reviewer found insufficient clinical information to support a terminal prognosis. The inspector general classified $251,067 in sampled payments as unallowable for that reason.

The question was whether the medical record supported the physician’s prognosis when the patient entered hospice. A signature belongs with the clinical findings that explain the judgment. The reviewer examined that support, beyond the presence of a certification form.

Missing Eligibility Documents

For the other 24 periods with errors, the medical records failed eligibility documentation requirements. The inspector general classified $294,432 in sampled payments as unallowable in this category.

For seven enrollees, hospices supplied no records at all. Seven files lacked required election statement elements, five had no certification of terminal illness, three had no election statement, and two lacked required certification elements such as signatures. The election statement matters because it records the patient’s choice of hospice and understanding that the health care focuses on comfort rather than a cure.

The audit also sets out the timing: written certification must be on file before billing and may be completed no more than 15 calendar days before the election takes effect or the next benefit period begins. An insider may know when the documents were actually prepared and whether the clinical observations changed before the claim went out.

$255.1 Million in Potential Savings From Eligibility Reviews

The hospice new enrollee audit’s savings estimate has specific limitations: it projects what Medicare could have avoided paying within the selected population if its contractors had eligibility review procedures for that group.

What the Medicare Agency Agreed to Do

The hospice Medicare Administrative Contractors process and pay claims and conduct eligibility reviews. Their screening included unusual billing patterns, very long stays and claims from new providers. The inspector general found that their reviews had not specifically targeted new enrollees without the hospital-claim history used in this audit.

The inspector general recommended that the Medicare agency work with those contractors to consider this risk area and possibly develop reviews before or after payment. The agency agreed to share the report so contractors could decide whether to prioritize this group. After the audit found paid claims with missing support, the response was still to consider whether to review them.

In its response, the agency also described its Service and Spending Variation Index, which uses claims data to flag potential risks. Its measures include length of stay, care minutes and patients discharged alive who soon return to the same hospice.

Why the Enrolled Days Matter

Medicare’s daily payment makes the duration of a hospice stay financially important. The connection between enrolled days and paid claims begins with a payment that covers the plan of care, regardless of which services staff provide on a particular day.

Milliman’s Hospice Medicare Margins, published in July 2019, explains why the work and the revenue can diverge:

A longer stay can extend the lower-cost middle while daily payments continue. The report describes the payment reforms intended to align reimbursement more closely with that pattern, including higher routine home care payments early in a stay and lower payments later.

The analysis, commissioned by the National Partnership for Hospice Innovation, also found that 32% of nonprofit hospice patients had an inpatient stay within the week before hospice, compared with 22% of for-profit patients in its 2017 data. Milliman interpreted the difference as consistent with nonprofits admitting patients with greater care needs and higher initial costs.

Together, the payment design and the study give an economic reason to examine who enters hospice and how much care they need.

What an Insider Can Put Beside the Claims History

For a healthcare insider, the patient file can show how a clinical observation became a certification and then a bill. An internal review or management instruction can show who knew the file was incomplete, or who wanted it changed.

In a complaint concerning Guardian Hospice, whistleblowers alleged that internal reviews identified missing signed election forms, inadequate admission or recertification support, and physician narratives that failed to support eligibility. They also alleged that Guardian demanded fabricated, backdated documentation to support the billing periods. The alleged response to the missing records is as important as the missing records themselves.

A separate complaint concerning Evercare Hospice alleged pressure on what staff recorded about the patient’s condition:

These separate allegations show what internal knowledge can add to a claims pattern: how the file was assembled, what observations were downplayed and what management asked staff to do. For hospice whistleblowers, we connect that knowledge to the certification, the election and the claims. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When You Know What Went Into the File

If you saw admission records rewritten, missing support ignored or pressure to certify patients whose condition told a different story, talk to our whistleblower experts about those decisions. We work with you to build your strongest hospice whistleblower case around the patient records, internal instructions and Medicare claims, and bring in hospice fraud whistleblower lawyers who understand disputed eligibility. We stay beside you from assessing what you know through pursuing the case.