2025 Proposed Rule Seeks to Clarify Physician Certification of Hospice Patients

The U.S. Centers for Medicare & Medicaid Services’ (CMS) proposed 2025 hospice rule contains clarifications on which physicians may certify patients for hospice enrollment.

According to language in the proposal, designated physician members of the hospice interdisciplinary team may certify patients for hospice if the medical director is unavailable. The clarification was intended to reconcile differences between the agency’s Conditions of Participation (CoPs) and its Conditions of Payment, according to Katie Wehri, director of home care and hospice regulatory affairs for the National Association for Home Care & Hospice (NAHC). 

“This was necessary because there are discrepancies between the regulations and payment requirements. Some of the regulations do not include the medical director of the hospice, physician designee if the medical director is not available, or the physician member of the hospice interdisciplinary group as the allowed certifying physicians,” Wehri told Hospice News in an email. “Clarification from CMS in these areas will be helpful to hospices, physicians and those reviewing hospice records for compliance.”

The CoPs require that a hospice medical director or physician designee review patient clinical information and provide written certification of their terminal illness. However, other regulations indicate that the hospice medical director or a physician member of the hospice interdisciplinary team can perform those functions, Patrick Harrison, senior director of regulatory and compliance at the National Hospice and Palliative Care Organization (NHPCO), and Sarah Simmons, director of quality for NHPCO, indicated in an email to Hospice News.

But the potential confusion didn’t stop there. Yet another set of rules require that the hospice medical director consider certain information in reaching a decision to certify a patient’s terminal illness.

“This discrepancy has resulted in significant confusion, and NHPCO has advocated for a need to align the federal hospice regulations regarding certification,” Harrison and Simmons said in a joint email. “To elect hospice care under the Medicare benefit, an individual must be entitled to Medicare Part A benefits and be certified as being terminally ill with a life expectancy of six months or less if their illness runs its normal course. However, federal regulations are inconsistent as to which physicians can certify a patient as being terminally ill under Medicare.”

In addition to this clarification, the proposed rule included a recommended payment rate increase of 2.6% as well as a number of changes to quality reporting requirements and requests for information on higher-acuity palliative services, health equity and social determinants of health.

Compliance on certification and associated documentation is crucial. Patient eligibility is a frequent focus of hospice audits, with documentation errors or omissions often at the root of identified issues.

The language in the proposed rule does not contain any new requirements, nor is it a part of CMS’ efforts to combat fraud, according to Mollie Gurian, vice president of home-based and HCBS public policy for LeadingAge.

“From a program integrity perspective, no, I don’t see any potential for change, because It’s just making consistent the CoPs with the Conditions of Payment, and making sure that a hospice could be using all the physicians that are available and eligible to do that certification under the circumstances that CMS lays out,” Gurian told Hospice News.