27 Nov Navigating Hospice Billing
Avoiding Common Billing Mistakes That Lead to Revenue Loss for Hospice Care Agencies
Hospice revenue leakage often results from preventable causes, which often occur upstream from billing. As healthcare leaders face margin erosion from rising costs, good billing practices can help preserve operating margins. By avoiding these common, costly mistakes, hospices can protect revenue and cash flow.
Complexity Amplifies Risk
Hospice billing is uniquely complex. Submitting a clean claim depends on orchestrating documentation across multiple stakeholders, from admission nurses to physicians, social workers and team nurses, and sometimes even people outside of the hospice the organization, such as community physicians, hospital case managers, or staff inside other hospices.
With so many boxes to check before a claim can be submitted, multiple potential points of failure threaten the billing process. Hospice billing’s vulnerability is further exacerbated by strict time frames. Additionally, sequential billing requirements which require one claim to process before subsequent claims can be processed, increase the potential for losses.
Billing Starts at the Time of Referral and Admission
Errors at admission are some of the most costly and preventable sources of revenue loss because they can impact all the claims that follow. Common errors that occur at the time of admission include:
Wrong Payer
Often, hospice staff admit patients under the wrong payer. While billing team members typically work during the week, intake and admissions teams work after hours. This can make weekend admissions particularly vulnerable to payer and eligibility issues. Hospice staff frequently rely on verbal information provided by hospitals or family members, which may be incomplete or incorrect.
For example, if the patient has commercial insurance listed as their primary insurance, but it turns out the commercial plan is supplemental and that the patient has Medicare as the primary, this can result in a late NOE and lost revenue. It can take weeks or months before a claim is denied by the commercial insurer and the error discovered, leading to significant losses. Tools like Hospice software with integrated billing functionality can always mitigate many common mistakes, but solid systems for review and data integrity are still essential.
Hospice-to-Hospice Transfers
Hospice-to-hospice transfers are a frequent source of avoidable billing errors. Billing issues arise when the transfer date is entered incorrectly or a discharge from the prior hospice is not properly reflected in Medicare’s system, leading to overlapping dates of service. Because benefit periods follow the patient, any misalignment can cause claim rejections, delayed payments, or days of losses.
Hospice teams facilitating transfers need to correctly identify whether a new patient is a transfer or a new admission, as it impacts Medicare claim submissions. They must also ensure that the dates align and that the transfer criteria is met, versus following the new admission process. A transfer must happen on the same day in the documentation for both hospices. If there is any gap in days, the election is no longer treated as continuous and a new one is needed.
Documentation errors
With so many documentation and timing requirements that must be met in order to receive payment, hospices lose a lot of revenue as the result of:
Level of Care Errors
Some common level of care errors made by clinical teams that impact billing include:
- GIP stays without adequate documentation, which can lead to ADRs.
- Continuous Care visits missing start/stop times.
- Late or incomplete change-of-LOC orders.
When clinical and billing teams are not aligned, revenue is at risk. Clinical teams should review level of care regularly to ensure that documentation captures the actual care provided. Additionally, most EMRs can be configured to:
- Require start/stop times on Continuous Care
- Restrict LOC submission until justification fields are complete
- Trigger notifications when GIP notes are delayed
- Require entry of orders before LOC is finalized
Election Statement Deficiencies
Election statement errors also create exposure: undated elections, incorrect dates of service, or incomplete patient/representative signatures jeopardize the validity of the entire hospice election, potentially putting significant amounts of revenue at risk
Unsigned Certifications
When physician certification signatures are missing or late, the claim remains unbillable. In addition to holding its own medical staff accountable, hospices may need to obtain signatures from external parties when a patient chooses a community attending physician. If a signature cannot be obtained quickly, billing is at risk.
Hospices can address signature requirements with physician dashboards, communication and prioritization by physician leadership, and an escalation process. A missing certification can cost a hospice tens of thousands of dollars.
Face To Face Visits
If a required face-to-face encounter does not occur timely, per CMS, hospices must discharge the patient. In this situation, CMS expects the hospice to continue providing care for the patient, without reimbursement, until the required face-to-face visit occurs. The hospice needs to readmit the patient and ensure that all the new admission criteria is again met in order to be paid.
Timely NOE Submissions
Claims cannot be paid until a Notice of Election (NOE) is submitted and accepted, and providers only have 5 calendar days to submit a timely NOE. Potential causes of late NOEs and associated losses include:
- Work Backlogs. Due to the time sensitive nature of NOEs, the clock is ticking. Weekends, staff turnover, understaffing, etc. can put NOEs and the subsequent claims at risk. Coding backlogs might also impact timely NOE submission.
- Retroactive Medicare Eligibility. It can be challenging to identify patients who retroactively qualify for Medicare, and ensure that all Medicare requirements are met, including a timely NOE.
- Technical issues with clearinghouses or hospice EMR.
- Missing physician information can delay an NOE.
- Incorrect start of care dates. If a start of care date is backdated or corrected later, the NOE window may have already closed before billing receives the accurate date.
Mitigating Revenue Loss
Because of the number and complexity of the items needed in order to bill for hospice services, many of which depend on clinical staff who are already spread thin, hospices must create strong processes to quickly identify and close any gaps impacting billing.
Communication is Key
Successful organizations design effective communication pathways, structured handoffs, automated alerts, clear accountability, and escalation processes. At high-performing hospices, revenue cycle leadership is visible, and billing and clinical teams function as partners, not separate entities. They track denial trends, quantify the impact, and report to clinical leadership monthly.
Other best practices include cross-training staff, daily claim‐readiness audits, monthly cross-functional reviews across clinical, finance, and operations, standardized checklists for NOE/NOTR, face-to-face, and LOC validation, and real-time dashboards for claim status visibility.
The Takeaway
Hospice billing is not just a back-office function. Many crucial pieces of the revenue cycle take place upstream in admissions and at the bedside. One missing requirement can derail all of the billing for a hospice stay. To protect revenue, hospice leaders need reliable, automated processes and organization-wide awareness of hospice billing requirements.
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Author’s Note: Views, information, and guidance in this resource are intended for information only. We are not rendering legal, financial, accounting, medical, or other professional advice. Alora disclaims any liability to any third party and cannot make any guarantee related to the content.
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When you’re automatically empowered with the right software, billing and financial efficiency become far less worrisome. The right Hospice EMR solution that facilitates compliance, workflow, and efficiency can strengthen your entire agency’s operations, ongoing and every day.
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