Hospice Durable Medical Equipment Double Billing: When Medicare Pays Again for Equipment Hospice Should Cover

Hospice GW modifier DME billing turns on whether the equipment is unrelated to the patient’s terminal illness and related conditions. Related durable medical equipment belongs in the hospice payment. A separate supplier claim can make Medicare pay for it again. If you handle equipment orders, supplier invoices or healthcare billing, the question reaches beyond the code on the claim. Who decided the equipment was unrelated, what supported that decision, and who told the supplier to bill Medicare?

Who Pays When a Patient Is in Hospice?

The hospice takes responsibility for the covered care related to the terminal illness, including equipment and supplies. Medicare’s routine home care payment pays the hospice by the day, with that responsibility included. Durable medical equipment belongs inside the package of care the hospice has agreed to provide.

That payment structure explains this form of hospice fraud. When a hospice knowingly shifts a covered equipment expense to a separate Medicare claim, it keeps the payment intended to cover the care while asking the program to finance that care again. The money intended for the patient’s care becomes a saving for the hospice and another bill for taxpayers. Honest hospices pay for that equipment out of their own daily payment.

A 2026 Kansas State University paper, Quality, Reputation, and Reimbursement Design in the Hospice Industry, examines the business pressure behind the daily payment. Its model of California hospices finds that reputation encourages spending on quality, while lower reimbursement reduces the quality they choose to provide. The paper measures quality through visits and includes equipment and oxygen in its accounting of care costs.

Providing durable medical equipment costs money out of the daily payment. Moving a covered expense outside that payment leaves the hospice with less to pay for the same enrolled patient.

What Is Not Covered Under Hospice?

Care unrelated to the terminal illness and related conditions can remain covered by Medicare outside the hospice benefit. The dividing line is the patient’s clinical needs and how the item relates to them. The Centers for Medicare & Medicaid Services says the hospice should provide virtually all care needed by the terminally ill patient. The decision to exclude equipment therefore calls for a patient-specific explanation that the outside supplier can compare with the order.

CMS says that coverage decisions must consider the patient’s condition, principal diagnosis, other conditions and current clinical information. The hospice’s explanation for excluding durable medical equipment needs to account for the patient’s other conditions, too.

GW Identifies Unrelated Care

GW identifies services unrelated to the terminal illness on professional claims. Condition code 07 identifies unrelated services on institutional claims. The Centers for Medicare & Medicaid Services sets out that distinction in its claims-processing guidance effective April 1, 2025.

The same guidance associates GV with related services provided by the patient’s designated attending physician.

For hospice durable medical equipment billing, the assertion behind GW is the important part: the item is being treated as unrelated. We compare that assertion with the hospice’s clinical explanation and the equipment’s purpose. The code communicates the billing position. The patient records explain the basis for it.

When Medicare denies a claim because it overlaps hospice coverage and leaves off the required indicator, the provider bears the cost.

When the Hospice Tells Someone Else to Bill Medicare

The Centers for Medicare & Medicaid Services has received reports of hospices directing outside providers to bill Medicare for services, alongside reports of hospices failing to pay for care that should be their responsibility.

In its August 2026 final rule, the agency described outside providers who could not get a requested election addendum, could not reach the hospice, or received no communication about care the hospice considered unrelated. Other providers sought payment from hospices for services the hospices should cover and reported unpaid services or unanswered requests.

For someone in supplier accounts receivable, that is a recognizable dispute: who accepted responsibility for the care, who refused the invoice, and where the bill went next. A direction to bill Medicare becomes especially significant when the clinical explanation still places the equipment within hospice care.

This is where an equipment transaction connects to the hospice billing decision. The agency expressly describes duplicate Medicare payment when outside providers bill for care that should have been the hospice’s coverage responsibility. The supplier’s order, the hospice’s decision and the separate claim belong in the same account of what happened.

The Equipment Appears in Medicare’s Spending Review

CMS’s review of fiscal 2024 claims found equipment and supplies billed outside the hospice benefit during hospice stays. Its examples include wound care supplies, catheters, wheelchairs, oxygen supplies and hospital beds.

An audit of hospice DME claims using the GW modifier asks why the equipment was treated as unrelated. The agency’s final rule cites a November 2021 audit by the Department of Health and Human Services Office of Inspector General estimating $117 million in improper supplier payments over four years for durable medical equipment, prosthetics, orthotics and supplies provided to hospice patients.

Commenters told CMS that GW and condition code 07 can let claims through without anyone examining whether the care really was unrelated.

For an insider, the useful comparison is between what the claim says and what the care records describe. We examine the clinical decision, the communication to the supplier and the payment together.

Beneficiary Cost Sharing Follows the Payment Route

Billing care outside the hospice benefit can put costs on the beneficiary as well as Medicare. Care the Centers for Medicare & Medicaid Services calls exceptional, rare and unusual still generated over $2 billion in non-hospice Part A and Part B payments during hospice elections in fiscal 2024.

The same analysis reported $510 million in beneficiary cost sharing for that care. These figures cover non-hospice Part A and Part B services across the program, beyond equipment alone.

Medicare’s payment to the hospice covers the patient’s bill for covered hospice care, apart from the hospice benefit’s coinsurance.

That makes a beneficiary statement another part of the equipment inquiry. We look at the charge alongside the coverage decision and Medicare’s payment or denial. Who received the bill matters as much as who submitted it.

When Do I Need a Hospice Election Statement Addendum?

For hospice elections beginning on or after October 1, 2026, the Centers for Medicare & Medicaid Services requires the hospice to provide the patient or representative a written election statement addendum, ordinarily within the first five days.

The addendum identifies the conditions, items, services and drugs the hospice has determined are unrelated and will not cover. Its required content includes the terminal illness and related conditions, the excluded care, and a clinical explanation in language the patient or representative can understand. The document must also be available to outside providers and Medicare contractors.

For an equipment claim, this creates a specific comparison: the item billed as unrelated and the hospice’s written reason for leaving it outside the benefit. The explanation can be compared with the plan of care and the purpose of the equipment.

What If a DME Supplier Was Unaware the Patient Was in Hospice?

When a DME supplier says it was unaware the patient was in hospice, an overpayment inquiry needs to establish what information reached the supplier and when. Medicare status checks and the hospice’s communications with the supplier help show what each knew.

Hospices must keep communication open among the healthcare providers caring for the patient, including suppliers furnishing unrelated services. The agency’s reports of missing addenda and unanswered calls make that communication a concrete issue. The relevant exchange may concern whether hospice coverage existed, whether the equipment was considered related, or whether the hospice would pay the invoice.

Those are different decisions made by people in different roles. A billing employee may know what instructions arrived. A hospice clinician may know why the equipment was needed. A manager may know who decided which payer would receive the claim. We work through those accounts with the records that connect them.

What an Insider Can Show About the Equipment Claim

The strongest account connects the equipment, the patient’s hospice election, the coverage decision, the claim and the payment. It also explains who knew what when the billing decision was made.

An order and delivery record connect the item to the patient. The plan of care and election addendum explain the hospice’s clinical and coverage position. The supplier invoice and claim show where payment was sought, while the remittance and beneficiary statement show how the charge was handled. We use those connections to understand the transaction you saw.

A hospice fraud whistleblower may hold the missing explanation: why an invoice went unpaid, who instructed staff to treat equipment as unrelated, or what happened after a clinician questioned that decision. An email explaining the billing instruction can connect the health care decision to the claim in a way the claim alone cannot.

We assess that evidence with you and build the case around the covered care, the separate payment and the decisions inside the business. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When You Know Why the Bill Went Elsewhere

If you know who directed equipment costs away from the hospice and onto Medicare, talk to our whistleblower experts about that billing decision. We work beside you to connect the clinical explanation, supplier communications and payments into your strongest hospice whistleblower case. We bring in hospice fraud whistleblower lawyers who understand Medicare equipment billing and stay with you through the case.