Top 5 Hospice Claim Denials and How to Prevent Them: Medicare Audit Insights for 2025

1. Prognosis Not Supported

Most common cause: 53% of all denials

This denial occurs when the medical documentation fails to demonstrate that the patient’s condition is terminal—defined by Medicare as a life expectancy of six months or less if the disease runs its normal course.
Common documentation weaknesses include:

• Repetitive or “stable” visit notes with no evidence of decline.
• Missing clinical indicators
• Lack of eligibility documentation between benefit periods.

How to prevent:

• Include measurable evidence of decline
• Document patient-specific changes in function and symptom burden.
• Ensure IDG notes and nursing narratives support the physician’s certification.

2. Invalid Notice of Election

Second leading cause: 33% of denials

The Notice of Election (NOE) is a legal declaration that begins the hospice benefit period. Errors such as missing signatures, incorrect effective dates, or late submissions make the NOE invalid.

Common pitfalls:

• NOE submitted after the five-day window.
• Missing beneficiary or representative signature.

How to prevent:

• Audit NOEs daily for timeliness and completeness.
• Validate all fields (dates, NPI, signatures) before submission.
• Retain electronic and paper copies for audit purposes.

3. Face-to-Face Encounter Deficiencies

This denial applies to recertifications beginning the third benefit period and beyond.
When the face-to-face visit is late, missing, or inadequately documented, the recertification is invalid.

How to prevent:

• Track all due F2F encounters in a compliance calendar.
• Include a narrative summary signed and dated by the physician or NP.
• Ensure documentation directly supports ongoing terminal decline.

4. Records Not Received Timely

Missing an ADR submission deadline can result in an automatic denial—even if the claim was fully defensible.

How to prevent:

• Use a TPE/ADR tracking log to monitor deadlines.
• Confirm MAC receipt via fax or portal upload confirmation.
• Assign a compliance designee to oversee all audit timelines.

5. Missing or Invalid Physician Narrative

A valid narrative must reflect individualized clinical judgment—not just a restatement of the diagnosis or copy-pasted text.

How to prevent:

• Require narratives to include specific clinical factors (e.g., “patient is bedbound, nonverbal, PPS 30%, progressive weight loss of 12 lbs over 30 days”).
• Physician must sign and date the narrative personally.
• Avoid using templated or repetitive language across patients.

Most Medicare hospice claim denials occur because of weak or incomplete documentation that fails to support a terminal prognosis of six months or less. Strengthening clinical records with clear evidence of decline, updated PPS or FAST scores, and detailed physician narratives can significantly reduce audit risk. Administrative errors—such as late or invalid Notices of Election (NOE), missing signatures, or untimely face-to-face encounters—remain another leading cause of denials and are easily preventable with routine compliance checks. Hospices should also track and confirm every ADR or TPE submission to avoid automatic denials for untimely responses. Finally, regular staff education on eligibility requirements, documentation standards, and Medicare audit expectations is one of the most effective ways to lower denial rates and maintain compliance.

✉️ Need Help Reducing TPE Denials?

Hospice Quality Solutions provides customized audit support, staff education, and documentation tools to help your hospice demonstrate compliance and avoid costly recoupments.

📧 tclark@hospicequalitysolutions.com
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