Changing Hospice Certifying Physician Enrollment:  Starting in June, Physicians Must Be Enrolled or Opted-Out of Medicare for CMS to Pay Hospice Claims

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On April 26, 2024, the Centers for Medicare and Medicaid Services (CMS) issued Questions and Answers concerning new hospice enrollment requirements for certifying physicians (CMS Q&As).[i]  In a nutshell, as of June 3, 2024, the following physicians must either be enrolled or opted-out of Medicare in order for CMS to pay for the hospice service:

1. Hospice medical director or the physician member of the hospice interdisciplinary group who certifies the patient’s terminal condition (hereafter occasionally referenced as “hospice physician”)
2. Patient-designated attending physician (if they have one) who certifies their terminal condition[ii]

Pursuant to 42 C.F.R. § 418.22, both of the two categories of physicians must provide the written certification of eligibility for hospice statement for the initial 90-day period, and thereafter for subsequent periods only  the  hospice physician needs to certify the additional hospice periods.[iii]   Aside from the requirements related to enrollment or opting out of Medicare, nothing else is changing under to 42 C.F.R. § 418.22.[iv]

What Actions do Hospice Physicians Need to Take?  If the physician is already enrolled or opted-out of Medicare, the physician does not have to do anything.  In addition, the physician does not need to list “hospice” as their specialty on their enrollment application in order to certify Medicare hospice patients.[v] 

How Can a Hospice Check on Physician Enrollment or Opt-Out Status?  Hospices can verify a physician’s enrollment or opt-out status on the CMS Order and Referring site (ORDF).[vi]  It is important to make sure the ORDF column indicates the physician is authorized by Medicare to make hospice certifications.[vii]  

Are There Limits on Opt-Out Physicians?  As noted by the Palmetto GBA Medicare Administrative Contractor, not all opt-out physicians can provide written hospice certifications. A physician cannot certify if the physician either did not respond with all the information to be an opt-out physician with ordering/certifying/referring rights or had their Medicare enrollment revoked for adverse actions.[viii] 

What Happens if the Physician’s Enrollment Status Changes?  The physician only needs to be enrolled or opted out at the time the physician made the certification or recertification.  In addition, the hospice does not need to replace the certification the previously enrolled or opted out physician signed.[ix] 

How Does a Hospice Need to Fill Out the Claims Forms?  Starting June 3, 2024, CMS will verify the enrollment/opt-out status of the physician listed in the “Attending Physician” field of the Medicare hospice claim.  Therefore, if the physician entered in the “Attending Physician” field is eligible to certify in PECOS records, Medicare will not reject the claim.[x]  

What About Physician Assistants (PA) and Nurse Practitioners (NP)?  Because PAs and NPs cannot certify or recertify a patient for hospice, the PAs and NPs do not need to be enrolled or opted-out for that purpose.[xi]  However, generally the PAs and NPs need to be properly enrolled or opted-out if the PA or NP plans to certify, refer, or order services.[xii]

In summary, certifying physicians need to understand their Medicare enrollment or opt-out status before completing written hospice certifications.  In turn, hospice providers need to confirm the enrollment or opt-out status of their certifying physicians in order to avoid denied payments, audits, and/or overpayments that may result if the certifying physicians are not properly enrolled or opted-out of Medicare.

If you need assistance with CMS enrollment issues, defending reimbursement audits, or other healthcare regulatory issues please reach out to Maynard Nexsen for assistance.

_{[i] CMS Q&A at Hospice Cert Enrollment Q&A (cms.gov).
[ii] Id.
[iii] 42 C.F.R. § 418.22(c)(2) at eCFR :: 42 CFR 418.22 -- Certification of terminal illness.
[iv] CMS Q&A.
v] Id.
[vi] Id.; Order and Referring - Centers for Medicare & Medicaid Services Data (cms.gov)
[vii] Id.
[viii] https://www.palmettogba.com/palmetto/jmhhh.nsf/DIDC/45IIQDZ2ZO~Hospice
[ix] CMS Q&A.
[x] Id.
[xi] Id.
[xii] https://www.palmettogba.com/palmetto/jmhhh.nsf/DIDC/45IIQDZ2ZO~Hospice}