Department of Health and Human Services
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
MED ICARE HOSPICE CARE  
 
B  
FOR  ENEFICIARIES 
 
 
N F :
IN  URSING  ACILITIES  
 
C   W M
OMPLIANCE  ITH  EDICARE 
 
C R  
OVE RAGE  EQUIREMENTS
 
 
Daniel R. Levinson  
Inspector General 
 
September 2009 
OEI-02-06-00221 
 
   
 
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities. 
 
   
   
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 E X E C U T I V E   S U M M A R Y  
OBJECTIVES 
To determine the extent to which hospice claims for beneficiaries in 
nursing facilities in 2006 met Medicare coverage requirements. 
BACKGROUND 
The Medicare hospice benefit allows a beneficiary with a terminal 
illness to forgo curative treatment for the illness and instead receive 
palliative care.  The number of beneficiaries receiving hospice care has 
increased significantly in recent years, and some studies suggest that 
the use of hospice care has grown most rapidly in nursing facilities.  In 
addition, previous Office of Inspector General work has raised questions 
about the hospice benefit for nursing home residents.  However, little 
subsequent research has been done to examine hospice care for these 
beneficiaries, and almost no beneficiary-specific data exist.   
This report determines the extent to which hospice claims for 
beneficiaries in nursing facilities in 2006 met Medicare coverage 
requirements.  We based this study on data from a medical record 
review of a stratified random sample of hospice claims for beneficiaries 
in nursing facilities in 2006.  A companion report, Medicare Hospice 
Care:  Services Provided to Beneficiaries Residing in Nursing 
Facilities, determines the nature and extent of hospice services 
provided to beneficiaries in nursing facilities. 
FINDINGS 
Eighty-two percent of hospice claims for beneficiaries in nursing 
facilities did not meet at least one Medicare coverage requirement.   
Eighty-one percent of claims did not meet at least one Medicare 
coverage requirement pertaining to election statements, plans of care, 
services, or certifications of terminal illness.  An additional 1 percent of 
claims were undocumented.  Medicare paid approximately $1.8 billion 
for these claims. 
Claims from not-for-profit hospices were less likely to meet Medicare 
coverage requirements than those from for-profit hospices.  Specifically, 
89 percent of claims from not-for-profit hospices did not meet Medicare 
requirements, compared to 74 percent of claims from for-profit hospices.   
 
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E X E C U T I V E   S U M M A R Y  
Thirty-three percent of claims did not meet election requirements.  
For 4 percent of claims, there were no election statements.  For another 
29 percent of claims, the election statements did not meet one or more 
regulations.  Most commonly, the statements did not explain that 
hospice care was palliative rather than curative or that the beneficiaries 
waived Medicare coverage of certain services related to their terminal 
illnesses. 
For another 9 percent of claims, the election statements contained 
misleading language about the beneficiaries right to revoke the election 
of hospice care. 
Sixty-three percent of claims did not meet plan of care 
requirements.  For 1 percent of claims, the hospices did not establish 
plans of care for the beneficiaries.  For another 62 percent of claims, the 
plans did not meet at least one Federal requirement.  These plans of care 
were not established by an interdisciplinary group; they did not include 
necessary components, such as a detailed description of the scope and 
frequency of services; or they did not specify intervals for review, as 
required. 
For 31 percent of claims, hospices provided fewer services than 
outlined in beneficiaries plans of care.  For 31 percent of claims, the 
hospices did not provide the number of services outlined in the plans of 
care that they established.  Most commonly, the hospices provided 
services to the beneficiaries but not as frequently as called for in the 
plans of care.  In the most extreme cases, there was no documentation 
in the medical records of any visits for a particular service.   
Four percent of claims did not meet certification of terminal illness 
requirements.  For 4 percent of claims, the certifications were missing 
or did not meet one or more Federal requirements.  For these claims, 
the certifications did not specify that the individuals prognoses were for 
life expectancies of 6 months or less if the terminal illness ran its 
normal course; they were not supported by clinical information and 
other documentation in the medical records; or they were not signed by 
physicians. 
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RECOMMENDATIONS 
Based on the findings in this report, we recommend that the Centers for 
Medicare & Medicaid Services (CMS):  
Educate hospices about the coverage requirements and their 
importance in ensuring quality of care.  CMS should educate hospices 
about the coverage requirements, particularly for election statements, 
plans of care and their review, and certifications of terminal illness.  It 
should pay particular attention to not-for-profit hospices, given the higher 
rate at which their claims did not meet requirements.  
Provide tools and guidance to hospices to help them meet the 
coverage requirements.  These tools should include clear and specific 
instructions, such as model text for election statements, a checklist of 
items that must be in the plans of care, and guidance on complying with 
the certification of terminal illness regulations.  
Strengthen its monitoring practices regarding hospice claims.  CMS 
should effectively use targeted medical reviews and other oversight 
mechanisms to improve hospice performance and compliance with 
Medicare requirements, especially with respect to establishing plans of 
care and providing services that are consistent with these plans of care.  
Additionally, as we recommended in a previous report, CMS should 
conduct more frequent certification surveys of hospices as a way to 
enforce the requirements. 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CMS concurred with all three of our recommendations.  In response to 
our first recommendation, CMS stated that it has made presentations at 
industry conferences and participated in other events with hospice 
associations.  CMS also noted that its Web site has a training broadcast 
for State surveyors that is available to hospice providers.  CMS stated 
that it has educated providers about the requirements of the new 
Conditions of Participation (CoP), issued June 5, 2008.  These CoPs 
address patient care planning and the care of patients who reside in 
nursing facilities. 
In response to our second recommendation, CMS stated that it has issued 
new Hospice Program Interpretive Guidance, a tool used by providers 
and State Survey agencies to determine compliance with the CoPs.  CMS 
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E X E C U T I V E   S U M M A R Y  
also stated that it held three satellite training sessions to educate 
stakeholders on the new requirements.  We encourage CMS to continue 
educating providers and to give them detailed instructions that 
encompass the new requirements as well as existing requirements that 
have not been revised but are equally important.  We also encourage 
CMS to augment these efforts with specific tools that address the 
problems outlined in this report, such as model text for election 
statements.  
In response to our third recommendation, CMS stated that it will 
instruct Medicare contractors to consider the issues in this report when 
prioritizing its medical review strategies or other interventions.  CMS 
also stated that it will share this report and relevant claim information 
from OIG with the Recovery Audit Contractors.   
We have made changes to the final report based on CMSs technical 
comments, as appropriate.   
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 T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
 
 
I N T RO DUC T IO N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
 
 
F I N D IN G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
  Eighty-two percent of hospice claims for beneficiaries in 
nursing facilities did not meet at least one Medicare 
coverage requirement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
  Thirty-three percent of claims did not meet election 
requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
  Sixty-three percent of claims did not meet plan of care 
requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
  For 31 percent of claims, hospices provided fewer services 
than outlined in beneficiaries plans of care. . . . . . . . . . . . . . . . . . 15
  Four percent of claims did not meet certification of 
terminal illness requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
 
 
R E C O MMEN D A T ION S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Agency Comments and Office of Inspector General Response . . . 18 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
  A:  Hospice Payment Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
  B:  Confidence Intervals for Selected Estimates . . . . . . . . . . . . . . 21
  C:  Weighted Chi-Square Test Comparing Not-For-Profit 
and For-Profit Hospices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
D: Agency Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 
   
A C K NO WL E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 
 
   
   
 I N T R O D U C T I O N  
OBJECTIVE 
To determine the extent to which hospice claims for beneficiaries in 
nursing facilities in 2006 met Medicare coverage requirements. 
BACKGROUND 
The Medicare hospice benefit allows a beneficiary with a terminal 
illness to forgo curative treatment for the illness and instead receive 
palliative care, which is the relief of pain and other uncomfortable 
symptoms.  The number of beneficiaries receiving hospice care has 
increased significantly in recent years.  In fiscal year 2001, 
580,000 Medicare beneficiaries received hospice care.  In 2006, this 
number increased by 62 percent to 939,000 beneficiaries.  Medicare 
spending on hospice care rose from $3.6 billion in 2001 to $9.2 billion in 
2006.1   
Some studies suggest that the use of hospice care has grown most 
rapidly in nursing facilities.2  In addition, previous Office of Inspector 
General (OIG) work has raised questions about the hospice benefit for 
nursing home residents.  For example, OIG reported that in 1995, 
payment levels for hospice care in nursing homes may have been 
excessive.3  However, little subsequent research has been done to 
examine hospice care for these beneficiaries, and almost no  
beneficiary-specific data exist.4   
 
 
1 Centers for Medicare & Medicaid Services (CMS), Medicare Hospice Expenditures and 
Units of Care.  Available online at 
http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/downloads/FY05update_hospice_exp
enditures_and_units_of_care.pdf.  Accessed on March 27, 2009.  CMS analysis of Medicare 
Health Care Information System data for calendar year 2006 claims.  Provided by CMS on 
May 5, 2009. 
2 Office of the Assistant Secretary for Planning and Evaluation (ASPE), Use of 
Medicares Hospice Benefit by Nursing Facility Residents, March 2000; Medicare Payment 
Advisory Commission, Report to the Congress:  Medicare Beneficiaries Access to Hospice, 
May 2002, p. 5.  
3 OIG, Hospice Patients in Nursing Homes, OEI-05-95-00250, September 1997. 
4 Government Accountability Office (GAO), Medicare Hospice Care:  Modifications to 
Payment Methodology May Be Warranted, GAO-05-42, October 15, 2004, pp. 4 and 20; 
ASPE, Synthesis and Analysis of Medicares Hospice Benefit, March 2000. 
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I N T R O D U C T I O N  
This report is one in a series of four reports conducted by OIG that 
examine the hospice benefit for nursing facility residents.  This report 
determines the extent to which hospice claims for beneficiaries in 
nursing facilities met Medicare coverage requirements.  A companion 
report determines the nature and extent of hospice services provided to 
beneficiaries in nursing facilities.5   
An earlier report in this series found that 28 percent of Medicare 
hospice beneficiaries resided in nursing facilities for at least some time 
while they received hospice care in 2005.6  These beneficiaries were 
more than twice as likely as beneficiaries in other settings to have 
terminal diagnoses of ill-defined conditions, mental disorders, or 
Alzheimers disease.  Finally, another report in the series found a 
number of cases in which the use of respite care for nursing facility 
beneficiaries may have been inappropriate; these cases were referred to 
CMS for corrective action.7   
The Medicare Hospice Benefit 
The Tax Equity and Fiscal Responsibility Act of 1982 created the 
Medicare hospice benefit for eligible beneficiaries under Medicare 
Part A.8  The goals of hospice care are to help terminally ill beneficiaries 
continue life with minimal disruption and to support beneficiaries 
families and other caregivers throughout the process.  The care may be 
provided to individuals and their families in the home or other places of 
residence, such as a skilled or other nursing facility.  The care provided 
to families and other caregivers includes counseling, training to provide 
care for the individual, and bereavement counseling. 
To be eligible for Medicare hospice care, a beneficiary must be entitled 
to Part A of Medicare and be certified as having a terminal prognosis 
with a life expectancy of 6 months or less if the disease runs its normal 
course.  Upon a beneficiarys election of hospice care, the hospice agency 
 
 
5 OIG, Medicare Hospice Care:  Services Provided to Beneficiaries Residing in Nursing 
Facilities, OEI-02-06-00223. 
6 OIG, Medicare Hospice Care:  A Comparison of Beneficiaries in Nursing Facilities and 
Beneficiaries in Other Settings, OEI-02-06-00220, December 2007. 
7 OIG, Hospice Beneficiaries Use of Respite Care, OEI-02-06-00222, March 2008. 
8 The Tax Equity and Fiscal Responsibility Act of 1982,  122, P.L. No. 97-248  122,  
96 Stat. 324, 356, 42 U.S.C.  1395x(dd). 
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assumes the responsibility for medical care related to the beneficiarys 
terminal illness and related conditions.  This care is palliative, rather 
than curative.  The beneficiary waives all rights to Medicare payment 
for services related to the treatment of the terminal condition or a 
related condition but retains rights to Medicare payment for services to 
treat conditions unrelated to the terminal illness.9   
Beneficiaries are entitled to receive hospice care for two 90-day periods 
and unlimited 60-day election periods.10  The periods need not be 
consecutive.11  At the start of each period of care, a physician must 
certify that the beneficiary is terminally ill and has a life expectancy of 
6 months or less.12  Beneficiaries may revoke their election of hospice 
care and return to standard Medicare coverage at any time.13  Hospice 
care is provided by Medicare-certified hospice agencies, hereinafter 
referred to as hospices. 
Medicare coverage requirements for hospice services.  Pursuant to 
regulations, hospice services must be reasonable and necessary for the 
palliation or management of the terminal illness as well as related 
conditions.  Hospice services must also meet the following requirements 
to be covered by Medicare:14 
 The individual must elect hospice care in accordance with 
regulations.  
  A plan of care must be established as set forth in regulation before 
services are provided.  
  The services must be consistent with the plan of care.  
 A certification that the individual is terminally ill must be 
completed as set forth in regulation. 
 
 
9 42 CFR  418.24. 
10 Before 1990, hospice beneficiaries who were in hospice care for more than 210 days 
and still required such care were provided care by the hospices without charge to Medicare 
or the beneficiaries.  
11 42 CFR  418.21. 
12 42 CFR  418.22. 
13 42 CFR  418.28. 
14 42 CFR  418.200. 
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The election statement must explain the palliative rather than curative 
nature of hospice care, acknowledge that coverage of certain Medicare 
services are waived with the election, and include the signature of the 
beneficiary or representative.15  The plan of care must include an 
assessment of the patients needs, address the management of 
discomfort and symptom relief, and state in detail the scope and 
frequency of services needed.  The plan must be established by the 
attending physician, the medical director or physician designee, and an 
interdisciplinary group and be reviewed and updated at intervals 
specified in the plan.16  In addition, the services provided to the hospice 
beneficiary must be consistent with the plan.  Finally, the certification 
of terminal illness must specify that the individuals prognosis is for a 
life expectancy of 6 months or less if the terminal illness runs its normal 
course, must be supported by clinical information and other 
documentation in the medical record, and must be signed by a 
physician.17 
Hospice services.  The Medicare hospice benefit covers nursing care, 
medical social services, home health aide and homemaker services, 
physician services, counseling, physical therapy, occupational therapy, 
and speech-language pathology services.  It also includes short-term 
inpatient care, medical supplies (including drugs and biologicals), and 
the use of medical appliances.  In addition, the hospice benefit covers 
any other service that is specified in the plan of care as reasonable and 
necessary for the palliation and management of the terminal illness and 
related conditions and for which payment may otherwise be made under 
Medicare.18     
Levels of care.  The Medicare hospice benefit has four levels of care, and 
each level has an all-inclusive, prospectively determined daily rate.  The 
rate is paid to the hospice for each day that a beneficiary is in hospice 
care, regardless of the number of services furnished.  The four levels of 
care are:  routine home care, continuous home care, respite care, and 
general inpatient care.  Routine home care is the most common level of 
 
 
15 42 CFR  418.24(b). 
16 42 CFR  418.200. 
17 42 CFR  418.22. 
18 42 CFR  418.202(i). 
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care and includes, but is not limited to, nursing and home health aide 
services.  Appendix A provides detailed information on the four levels of 
care and the payment rates. 
Hospice care in nursing facilities.  When a beneficiary resides in a nursing 
facility, the hospice is responsible for providing the hospice services to 
the beneficiary.  The nursing facility provides room and board and care 
unrelated to the terminal illness.  Medicare reimburses the hospice 
according to the level of care provided, and the beneficiary or a third 
party payer pays the nursing facility for room and board costs.19  In the 
case of a nursing facility resident who is eligible for Medicaid, Medicaid 
pays the hospice, and the hospice pays the nursing facility.  
Related Work 
A 2007 OIG report reviewed the hospice survey and certification 
process.20  It found that Federal oversight of hospices was limited.  
Between FY 2000 and FY 2005, CMS required that hospices undergo 
certification every 6 years.  By contrast, nursing facilities and home 
health agencies must undergo certification at least every 15 months and 
36 months, respectively.  OIG determined that State agencies certified 
86 percent of hospices within the required timeframe, while 14 percent 
averaged 3 years past due.  In addition, 46 percent of hospices surveyed 
were cited with health deficiencies, a substantial proportion of which 
related to patient care planning and quality issues.  The report also 
found that CMS and State agencies rarely used methods other than 
certification surveys and complaint investigations to monitor or enforce 
hospice performance. 
METHODOLOGY 
We based this study on data from a medical record review of a stratified 
random sample of hospice claims for beneficiaries in nursing facilities.  
 
 
 
19 CMS, Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 9,  20.3.  Available 
online at http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf.  Accessed on  
February 10, 2009. 
20 OIG, Medicare Hospices:  Certification and Centers for Medicare & Medicaid Services 
Oversight, OEI-06-05-00260, April 2007. 
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Sample Selection 
Using the National Claims History file, we extracted all Medicare 
hospice claims that had service dates in 2006 and were received through 
December 2006.  Hospice claims typically cover a 1-month period but 
could be for shorter periods of time.  We matched the claims data to the 
Medicare Enrollment Database by health insurance claim number to 
identify the Social Security number for each beneficiary.    
Because hospice claims in 2006 did not include place of service, we used 
the Minimum Data Set (MDS) to identify nursing facility stay dates.  
The MDS includes assessments on all residents in Medicare- or 
Medicaid-certified nursing facilities.  We used the MDS assessments 
received from January 2004 through December 2006 to create a record 
for each beneficiary of the dates when he or she resided in a nursing 
facility.   
We matched the hospice claims to these nursing facility stay dates by 
the beneficiaries Social Security numbers to identify claims for 
beneficiaries while they resided in nursing facilities.  We created a file 
that included all hospice claims that corresponded to beneficiaries 
nursing facility stays.  This file included 812,668 hospice claims for 
231,978 beneficiaries. 
We selected a stratified random sample of 470 hospice claims from this 
file.  We stratified the sample to ensure that we included claims for 
beneficiaries who had high-dollar amount claims and had received 
hospice care while in nursing facilities for an extended period of time.  
This stratum comprised all claims for hospice beneficiaries with an 
average hospice reimbursement of $400 or more per day for at least  
60 days while in nursing facilities during 2006.  The other two strata 
comprised claims for all remaining beneficiaries who received hospice 
care while in nursing facilities:  one stratum included all claims for 
beneficiaries with maximum claim amounts of $3,000 or less, and the 
other included all claims for beneficiaries with maximum claim amounts 
of more than $3,000.  We then selected a random sample of claims from 
each stratum.  See Table 1 for more details. 
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I N T R O D U C T I O N  
 
Table 1:  Sample Selection 
 
Initial  Final 
 Description of Strata  Population 
  Sample  Sample 
 
Cla ims for beneficiaries with high  Average claim  
average daily claim amounts and  amount > $400/day  1,441  35  33 
exte nded nursing home stays  for at least 60 days 
    Maximum claim 
  279,697  85  82 
Claims for all other beneficiaries  amount < $3,000 
with  nursing home stays 
Maximum claim 
531,530  350  335 
amount > $3,000 
 
     Total claims  812,668  470  450 
 
We excluded 12 claims from our sample because the hospices were 
currently under investigation by OIG.  We excluded an additional claim 
because the beneficiarys nursing facility stay information was 
incomplete and an additional three claims because we were unable to 
locate the hospices. 21  We also excluded another four claims because the 
contractor erred in record collection.22  Our final sample included  
450 claims. 
As a last step, we identified the names and addresses of the hospices 
associated with each sampled claim by using the Online Survey and 
Certification Reporting System (OSCAR).  We matched the hospice 
provider numbers in the claims file with the OSCAR data.  We also 
identified hospices that were for-profit and those that were not-for-profit 
using a variable that indicated the type of provider ownership.  In total, 
43 percent of claims were from not-for-profit hospices and 53 percent of 
claims were from for-profit hospices.  The remaining 4 percent were for 
services provided by government hospices.   
Medical Record Review 
We used a contractor to collect and review the medical records 
associated with each sampled claim.  For each claim, we requested that 
the hospice provide the relevant hospice election statement, plan(s) of 
 
 
21 The hospices telephone numbers were disconnected and the hospices could not be 
reached by certified mail.  We have referred these cases to CMS for appropriate action. 
22 The contractor collected records for the wrong claim period in three cases and 
contacted the wrong provider in one case.  
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care,23 record of services provided (including those furnished under 
arrangement or contract with the hospice), certification(s) of terminal 
illness, and clinical information and other documentation that 
supported the medical prognosis.  Hospices are required to keep all of 
this information in the clinical record that they establish for every 
individual receiving care and services.24  We requested these records for 
the claim period and, if possible, for the 30 days preceding and the  
30 days following the claim period. 
The contracted reviewers included two registered nurses, each of whom 
had experience with hospice care.  For each claim, they used a 
standardized instrument to review the beneficiarys plan(s) of care, the 
services provided by the hospice, and the beneficiarys certification(s) of 
terminal illness.  As part of their review, they recorded the scope and 
frequency of the services outlined in the plan of care, identified the 
members of the interdisciplinary group who signed the plan, and noted 
the intervals for review specified in the plan.  Using the medical 
records, the reviewers also recorded all hospice services provided to the 
beneficiary during the claim period, with the exception of physician 
services.25  Finally, the reviewers determined whether the certification 
of terminal illness specified a prognosis for a life expectancy of 6 months 
or less, whether it was signed by a physician, and whether clinical 
information and other documentation in the record supported the 
medical prognosis.   
The contractor reviewed a total of 447 claims.  For the other three 
claims, the hospices did not provide any documentation to review.26  We 
included these three claims when determining the total percentage of 
claims that did not meet at least one Medicare coverage requirement.  
We did not include them when determining the percentages of claims 
that failed to meet each specific coverage requirement. 
 
 
 
23 Although only one plan of care is in effect at any given time, some beneficiaries had 
more than one plan of care during the claim period.    
24 42 CFR  418.74, Condition of Participation  Central Clinical Records. 
25 Services provided by the beneficiarys attending physician are not always included in 
the hospice record. 
26 We contacted the hospices by telephone and certified mail, but they did not provide the 
requested records.  We have referred these cases to CMS for appropriate action. 
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Analysis 
Based on the results of the medical record review, we determined 
whether the frequency of hospice services provided to the beneficiary 
was consistent with the frequency called for in the plan of care.  If the 
record indicated that services were missing because the beneficiary 
refused treatment, we considered the frequency of services provided to 
be consistent with the plan of care.  
We reviewed the hospice election statements associated with the sample 
claims.  We determined whether the statements addressed the 
palliative rather than curative nature of hospice care and whether 
certain Medicare services were waived by election.  We also determined 
whether the beneficiary or representative signed the statement.   
We compared the percentages of claims from not-for-profit and for-profit 
hospices that met the Medicare coverage requirements for election 
statements, plans of care, services, and certifications of terminal illness.  
We tested for statistically significant differences and noted in our 
findings when these differences occurred.   
See Appendixes B and C for the results of our statistical tests. 
Limitations 
This review determined whether hospice claims for beneficiaries in 
nursing facilities met key Medicare coverage requirements.   We did not 
determine whether the claims met every requirement.  For example, we 
did not analyze whether plans of care were reviewed within specified 
timeframes.  Also, we did not report on specific levels of care, such as 
general inpatient, because the results could not be projected to the 
universe. 
In addition, as part of the study, medical record reviewers determined 
whether each beneficiary associated with the sample claims had a 
certification of terminal illness and documentation supporting the 
medical prognosis in his or her medical record.  The reviewers did not 
assess eligibility status for the hospice benefit or independently verify 
the beneficiarys prognosis for a life expectancy of 6 months or less. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections approved by the Council of the Inspectors General on 
Integrity and Efficiency.
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  F I N D I N G S  
Eighty-two percent of hospice claims for  Hospices must meet certain 
 
beneficiaries in nursing facilities did not meet at  Federal requirements for their 
services to be covered by Medicare.    
least one Medicare coverage requirement  
In 2006, 82 percent of Medicare 
hospice claims did not meet one or more coverage requirements.  
Medicare paid approximately $1.8 billion for these claims.   
Eighty-one percent of claims did not meet at least one Medicare 
coverage requirement pertaining to election statements, plans of care, 
services, or certifications of terminal illness.  An additional 1 percent of 
claims were undocumented.  For these claims, the hospices did not 
submit any records to support the claims, as required.  Figure 1 and the 
following findings address the percentage of claims that did not meet 
each of the coverage requirements. 
 
80%
FIGURE 1: 
Percentage of 
63%
Hospice Claims   
60%
That Did Not 
Meet Specific 
Medicare   
40%
Coverage  33% 31%
Requirements   
  20% 
 
4%
 
0%
Claims that did not Claims that did not Claims that did not  Claims that did not
  meet election    meet plan of  care meet s ervice  meet ce rtification
  requirements   requiremen ts  requirem ents  of terminal illness
 
      requirements
 
 
  Source:  OIG analysis of medical record review results, 2008. 
Note:  Percentages are not mutually exclusive. 
 
Claims from not-for-profit hospices were less likely to meet Medicare 
coverage requirements than those from for-profit hospices.  Specifically, 
89 percent of claims from not-for-profit hospices did not meet Medicare 
requirements, compared to 74 percent of claims from for-profit hospices.  
This difference was statistically significant at the 95-percent confidence 
level.   
 
 
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F I N D I N G S  
Thirty-three percent of claims did not meet  Individuals who are terminally 
election requirements  ill and entitled to Medicare  
Part A may elect hospice care by 
filing election statements.27  For hospice services to be covered by 
Medicare, election statements must meet certain Federal regulations.28  
These regulations help to ensure that beneficiaries understand the 
types of services they will be receiving as well as forgoing under the 
hospice benefit.  Ensuring informed consent for hospice election is 
especially important as beneficiaries may be forgoing potentially  
life-saving therapies. 
For 4 percent of claims, there were no election statements.  For another 
29 percent of claims, the election statements did not comply with one or 
more regulations.  Most commonly, the statements did not explain that 
hospice care was palliative rather than curative or that the beneficiaries 
waived Medicare coverage of certain services related to their terminal 
illnesses.  In a few instances, the election statements were not signed by 
the beneficiaries or representatives. 
In addition, a greater percentage of claims from not-for-profit hospices 
did not meet election requirements compared to claims from for-profit 
hospices.  Thirty-nine percent of claims from not-for-profit hospices did 
not meet election requirements, compared to 25 percent of claims from 
for-profit hospices.  This difference was statistically significant at the  
95-percent confidence level. 
Some election statements misrepresented regulations 
For another 9 percent of claims, the election statements contained 
misleading language.  The following excerpts provide examples of such 
language: 
If I choose care or treatment that has not been preauthorized by 
the hospice team or included in the plan, I understand that I have 
removed myself from the hospice benefit effective immediately 
upon my action. 
 
 
27 42 CFR 418.24(a).  Physically or mentally incapacitated individuals may have their 
representatives file the election statements. 
28 42 CFR  418.200 and 418.24. 
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If I choose to be admitted to a hospital that does not have a 
contract with [named hospice], that admission will be considered a 
decision to revoke my Medicare/Medicaid hospice benefit election. 
Pursuant to Federal regulations, a beneficiary does not revoke the 
hospice benefit simply by entering a hospital without authorization from 
his or her hospice.  Rather, the individual must file a signed statement 
with the hospice that revokes the election for the remainder of that 
election period.29  Further, to discharge a patient for cause, the hospice 
must follow a number of steps outlined in Federal regulations, which 
include making a serious effort to resolve the problem.30 
 
Sixty-three percent of claims did not meet  For hospice services to be covered by 
plan of care requirements  Medicare, a plan of care must be 
established pursuant to Federal 
regulations for each hospice beneficiary.31  The plan of care helps to 
ensure that those involved in hospice care know precisely what is 
supposed to be done, by whom, at what time, and for what purpose.32  
For 1 percent of claims, the hospices did not establish plans of care for 
the beneficiaries.  For another 62 percent of claims, the plans did not 
meet at least one Federal requirement.  As discussed in more detail 
below, these plans of care were not established by interdisciplinary 
groups; they did not include necessary components, such as detailed 
descriptions of the scope and frequency of services; or they did not 
specify intervals for review, as required.  See Table 2. 
 
 
 
 
 
 
 
29 42 CFR  418.28. 
30 42 CFR  418.26. 
31 42 CFR  418.200. 
32 73 Fed. Reg. 32088, 32115 (June 5, 2008). 
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F I N D I N G S  
  Table 2:  Percentage of Claims That Did Not Meet Plan of Care 
Requirements 
 
Percentage 
   
of Claims* 
  Hospice did not establish plan of care  1% 
Plan of care was not established by an interdisciplinary group  34% 
 
Plan of care was missing a necessary component  31% 
 
Plan of care did not specify intervals for review  22% 
 
Plan of care did not meet at least one requirement listed above  63% 
 
Source:  OIG analysis of medical record review results, 2008. 
*Percentages are not mutually exclusive. 
 
In addition, a higher percentage of claims from not-for-profit hospices 
did not meet plan of care requirements compared to claims from  
for-profit hospices.  Seventy-five percent of claims from not-for-profit 
hospices did not meet plan of care requirements, compared to  
52 percent of claims from for-profit hospices.  This difference was 
statistically significant at the 95-percent confidence level. 
For 34 percent of claims, the plans of care were not established by 
interdisciplinary groups 
Federal regulations require that the plan of care be established by the 
attending physician, the medical director or physician designee, and an 
interdisciplinary group prior to providing care.33  The interdisciplinary 
group must include at least a doctor of medicine or osteopathy, a 
registered nurse, a social worker, and a pastoral or other counselor.34   
For 34 percent of claims, the plans of care were not established by all of 
the required members of the interdisciplinary groups.  Most commonly, 
pastoral or other counselors and social workers did not participate in 
the plans establishment (for 31 percent and 22 percent of claims, 
respectively).  Registered nurses did not participate for 5 percent of 
claims and physicians for 2 percent of claims.  
 
 
33 42 CFR  418.58(a). 
34 42 CFR  418.68(a). 
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F I N D I N G S  
For 31 percent of claims, the plans of care were missing a necessary 
component 
The plan of care must include an assessment of the patients needs; 
identification of services, including the management of discomfort and 
symptom relief; and a detailed statement of the scope and frequency of 
needed services. 35   
For 1 percent of claims, the plans of care were missing assessments of 
the patients needs; for 1 percent of claims, the plans were missing the 
management of discomfort and symptom relief; for 29 percent of claims, 
the plans were missing the scope of at least one service; and for  
1 percent of claims, the plans were missing the frequency of at least one 
service.36   
Most commonly, plans of care were missing the scope of services for 
home health aide and nursing services.  For 24 percent of claims, the 
plans of care called for home health aide services but did not include 
any details about the scope of this care.  Plans that provided the scope 
listed specific home health aide tasks, such as feeding and bathing the 
patient, helping with ambulation, and changing incontinence pads.  
Similarly, for 17 percent of claims, the plans of care called for nursing 
services but did not include any information about their scope.  Plans 
that included the scope described particular nursing duties, such as 
assessing and monitoring patients for various issues, including 
depression, anxiety, neuro-sensory status, pain type, and respiratory 
status. 
As noted earlier, the plans of care were missing the frequency of 
services for 1 percent of claims.  Other plans of care included 
frequencies but were somewhat vague.  For example, they called for 
certain services to be provided as needed or included a range as wide as 
one to seven visits per week or zero to five visits per month.37   
 
 
35 42 CFR  418.58(c). 
36 These percentages are not mutually exclusive. 
37 For 8 percent of claims, the plans of care called for services to be provided as needed.   
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F I N D I N G S  
For 22 percent of claims, the plans of care did not specify intervals for 
review  
The plan of care must be reviewed and updated at intervals specified in 
the plan.38  Frequent reviews and updates are especially important among 
the terminally ill population, given the potential for rapid changes in their 
conditions.   
However, for 22 percent of the claims, the plans of 
Table 3:  Length of Intervals for Review 
care did not include any such interval.  See  
in Plans of Care 
Table 3.  For another 37 percent of claims, the 
Length of Intervals   Percentage of Claims*  plans specified an interval of 90 days.  It should 
be noted that hospice beneficiaries are expected to 
7 days  <1% 
live for 6 months or less.  Therefore, beneficiaries 
14 days  20% 
who have plans with 90-day intervals could 
60 days  17% 
anticipate only one review during their expected 
90 days  37% 
time in hospice care.  
Other intervals  1% 
No interval specified  22%   
For 21 percent of claims, the plans of care had an 
No plan of care  1% 
interval of 14 or fewer days.  These would be the 
Source:  OIG analysis of medical record review results, 2008. 
only claims that would comply with a new rule, 
*Percentages do not sum to 100 percent because of 
rounding.  effective December 2008, mandating that the plan 
be reviewed and revised as frequently as the patients condition 
requires, but no less than every 15 days.39  
 
For 31 percent of claims, hospices provided fewer  To be covered by Medicare, 
services than outlined in beneficiaries plans of care  hospice services must be 
consistent with the plan of 
care.40  For 31 percent of claims, the hospices did not provide the 
number of services outlined in the plans of care they established.  Most 
commonly, the hospices provided services to the beneficiaries but not as 
frequently as called for in the plans of care.  In the most extreme cases, 
there was no documentation of any visits for a particular service.   
Failure to provide home health aide services was the most frequent 
error, but nursing and medical social services were also not provided as 
 
 
38 42 CFR  418.58(b). 
39 73 Fed. Reg. 32088, 32206 (June 5, 2008). 
40 42 CFR  418.200. 
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F I N D I N G S  
often as the plans of care specified.  For 8 percent of claims, the plans 
called for home health aide services, but no services were documented 
during the claim period.  For another 12 percent of claims, the hospices 
provided fewer home health aide services than specified in the plans.  
For 9 percent of claims, the hospices provided fewer nursing services 
than called for in the plans, and for 7 percent of claims, they provided 
fewer medical social services.  As mentioned earlier, hospices set their 
own standards for the number of services that beneficiaries needed, and 
these standards were, at times, quite broad.   
 
Four percent of claims did not meet certification  A certification that the 
of terminal illness requirements  individual is terminally ill 
must be completed pursuant 
to regulations in order for hospice services to be covered by Medicare.41  
For 4 percent of claims, the certifications were missing or did not meet 
one or more Federal requirements.  For these claims, the certifications 
did not specify that the individuals prognoses were for life expectancies 
of 6 months or less if the terminal illness ran its normal course, they 
were not supported by clinical information and other documentation in 
the medical record, or they were not signed by physicians. 
A greater percentage of claims from not-for-profit hospices failed to 
meet certification of terminal illness requirements compared to claims 
from for-profit hospices.  Six percent of claims from not-for-profit 
hospices failed to meet these requirements, compared to 2 percent of 
claims from for-profit hospices.  This difference was statistically 
significant at the 95-percent confidence level.
 
 
41 42 CFR  418.200. 
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 R E C O M M E N D A T I O N S  
We found that 82 percent of hospice claims for beneficiaries in nursing 
facilities in 2006 did not meet Medicare coverage requirements.  
Medicare paid approximately $1.8 billion for these claims.  The extent to 
which hospices did not meet coverage requirements raises concerns 
about the services that Medicare is paying for and the quality of care 
that hospices are providing to beneficiaries during their last months of 
life.  The results of our review also indicate that CMSs current 
oversight procedures are inadequate and that it must do more to ensure 
that hospices deliver care that meets Medicare requirements.   Given 
the nature of hospices noncompliancewhich does not appear to be 
related to the beneficiaries settingthese concerns extend to all 
Medicare beneficiaries receiving hospice care.  
Based on the findings in this report, we recommend that CMS:  
Educate Hospices About the Coverage Requirements and Their Importance 
in Ensuring Quality of Care 
Our findings raise questions about whether hospices are providing 
accurate information to individuals about the benefit upon election and 
whether they are furnishing needed services to beneficiaries at an 
especially vulnerable time in their lives.  CMS should educate hospices 
about the coverage requirements, particularly for election statements, 
plans of care and their review, and certifications of terminal illness.  It 
should pay particular attention to not-for-profit hospices, given the 
higher rate at which their claims did not meet requirements.  
Provide Tools and Guidance to Hospices To Help Them Meet the Coverage 
Requirements 
These tools should include clear and specific instructions, such as model 
text for election statements, a checklist of items that must be in the 
plans of care, and guidance on complying with the certification of 
terminal illness regulations. 
Strengthen Its Monitoring Practices Regarding Hospice Claims 
CMS should effectively use targeted medical reviews and other 
oversight mechanisms to improve hospice performance and compliance 
with Medicare requirements, especially with respect to establishing 
plans of care and providing services that are consistent with these plans 
of care.  Additionally, as we recommended in a previous report, CMS 
should conduct more frequent certification surveys of hospices as a way 
to enforce the requirements.  
 
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 R E C O M M E N D A T I O N S  
 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CMS concurred with all three of our recommendations.  In response to 
our first recommendation, CMS stated that it has made presentations 
at industry conferences and participated in other events with hospice 
associations.  CMS also noted that its Web site has a training 
broadcast for State surveyors that is available to hospice providers.  
CMS stated that it has educated providers about the requirements of 
the new Conditions of Participation (CoP), issued June 5, 2008.  These 
CoPs address patient care planning and the care of patients who 
reside in nursing facilities. 
In response to our second recommendation, CMS stated that it has 
issued new Hospice Program Interpretive Guidance, a tool used by 
providers and State Survey agencies to determine compliance with 
the CoPs.  CMS also stated that it held three satellite training 
sessions to educate stakeholders on the new requirements.  We 
encourage CMS to continue educating providers and to give them 
detailed instructions that encompass the new requirements as well as 
existing requirements that have not been revised but are equally 
important.  We also encourage CMS to augment these efforts with 
specific tools that address the problems outlined in this report, such 
as model text for election statements.  
In response to our third recommendation, CMS stated that it will 
instruct Medicare contractors to consider the issues in this report 
when prioritizing its medical review strategies or other interventions.  
CMS also stated that it will share this report and relevant claim 
information from OIG with the Recovery Audit Contractors.   
We have made changes to the final report based on CMSs technical 
comments, as appropriate.  For the full text of CMSs comments, see 
Appendix D.  
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 A P P E N D I X ~ A  
Hospice Payment Rates 
The Centers for Medicare & Medicaid Services (CMS) publishes general 
hospice payment rates annually to be used for each level of care.42  The 
rates are adjusted based on the beneficiaries geographic locations.  The 
levels of care and the fiscal year 2006 Medicare unadjusted daily rates 
for each are as follows: 
 Routine Home Care ($126.49):  The routine home care rate is paid to 
the hospice for each day that the beneficiary is under the care of the 
hospice and is not receiving one of the other categories of care.  
Routine home care includes, but is not limited to, nursing and home 
health aide services.  Routine home care may be provided in the 
home or other places of residence, such as a nursing facility. 
 Continuous Home Care ($738.26):  Continuous home care is allowed 
only during periods of crisis in which a beneficiary requires 
continuous care to achieve palliation or management of acute 
medical symptoms.  It is covered only as necessary to maintain the 
terminally ill beneficiary at home.  The care must be predominantly 
nursing care.  Continuous home care may be provided in the home 
or other places of residence, such as a nursing facility.  The 
continuous home care rate is divided by 24 hours to determine an 
hourly rate.  A minimum of 8 hours must be provided.   
 Respite Care ($130.85):  Respite care is short-term inpatient care 
provided to the beneficiary when necessary to relieve the 
beneficiarys caregiver(s).  Respite care may be provided only on an 
occasional basis and is not reimbursed for more than 5 consecutive 
days.  Respite care may be provided in a Medicare- or  
Medicaid-certified hospice inpatient facility, hospital, skilled 
nursing facility, or nursing facility. 
 
 
42 CMS, Medicare Claims Processing Manual, Pub. No. 100-04, ch. 11, Transmittal 663, 
Change Request 3977.  Available online at 
http://www.cms.hhs.gov/transmittals/downloads/R663CP.pdf.  Accessed on February 10, 
2009. 
 
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A P P E N D I X ~ A  
 General Inpatient Care ($562.69):  General inpatient care is for pain 
control and symptom management that cannot feasibly be provided 
in other settings.  General inpatient care may be provided in a 
Medicare- or Medicaid-certified hospice inpatient facility, hospital, 
or skilled nursing facility. 
 
      
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 A  AP PP PE EN ND DI IX X~ ~B B   
   
     Confidence Intervals for Selected Estimates 
 
95-Percent Confidence 
Estimate Description  n  Point Estimate 
Interval 
Percentage of hospice claims that did not 
450  82%  77%  85% 
meet Medicare coverage requirements 
Dollar amount paid by Medicare for claims 
that did not meet Medicare coverage  450  $1.8 billion  $1.7 billion  $1.9 billion 
requirements 
Percentage of undocumented claims  450  0.6%  0.2%  1.8% 
Percentage of claims that did not meet at 
least one Medicare coverage requirement 
pertaining to election statements, plans of  450  81%  77%  85% 
care, services, or certifications of terminal 
illness 
Percentage of claims that did not meet 
447  33%  28%  38% 
election requirements 
Percentage of claims that did not meet plan 
447 63%  58%  68% 
of care requirements 
Percentage of claims for which 
interdisciplinary groups did not establish the  447 34%  29%  39% 
plans of care 
Percentage of claims for which the plans of 
447 31%  27%  36% 
care were missing a necessary component 
Percentage of claims for which the plans of 
447 22%  18%  27% 
care did not specify the interval for review 
Percentage of claims for which the hospices 
provided fewer services than outlined in the  447 31%  26%  36% 
plans of care 
Percentage of claims that did not meet 
447 4%  2%  6% 
certification of terminal illness requirements 
Source:  Office of Inspector General analysis of medical record review results, 2008. 
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   A P P E N D I X ~ C  
    
     Weighted Chi-Square Test Comparing Not-For-Profit and For-Profit Hospices 
 
Percentage of Claims  Percentage of Claims 
  From Not-For-Profit  From For-Profit  P-Value 
Hospices  Hospices 
Percentage of claims that did not meet 
89%  74%  0.0002 
Federal requirements* 
Percentage of claims that did not meet 
39%  25%  0.009 
election requirements* 
Percentage of claims that did not meet 
75%  52%  <0.0001 
plan of care requirements* 
Percentage of claims for which the 
hospices provided fewer services than  31%  32%  0.91 
outlined in the plans of care 
Percentage of claims that did not meet 
certification of terminal illness  6%  2%  0.007 
requirements* 
Source:  Office of Inspector General analysis of medical record review results, 2008. 
*Differences between percentages of claims from not-for-profit hospices and those from for-profit hospices were statistically significant 
at the 95-percent confidence level. 
         
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A P PEN D
x D
Agency Comments
..,"'~ '''''C''~'.''. '
( E
DEPARTMENT OF HEALTH & HUMAN SERVICES
,.,;~ oenters for Medicare & Medi~aid SelVices
. ---~~:-i~: .... /-:u Administrator
Washington, DC, 2020'1
2009 AUG .. 7 PH 3: 0 S
..., ;c
GENEI,A L
DATE: 'AUG 0  2009
TO: Daniel R. Levinson
liispector Gen~ral
FROM: 'Charlene Frizzera
Acting Administrator
SUBJECT: Offce ofInspector General's Draft Report: "Medicare Hospice Care for
Bendiciaries in Nursing Facilities: Compliance with  Medicare Coverage
Requirements" (0 EI ~02-06-00221)
Thank you for the oppottiinity to review and comment on the Offce of inspector General's
(OlG) draft report entitled, "Medicare Hospice Care for Beneficiaries in Nursing Facilities:
Compliance with Medicare Coverage Requirements."
The objective of the report was to determine the extent to. which hospice claims for beneficiaries
in nursing iacilities in 2006 met Medicare coverage requirements. As noted in the report, the
number of  Medicare beneiiciaries receiving hospice care has increased significantly in recent
years and some studies suggest that the,  number of beneficiaries receiving hospice care while
residing in a nursing facility is also growing rapidly. This report found that 82 percent of
hospice claims for beneficiaries in nursing facilities in 2006  did not meet at least one Medicare
scope of benefit or coverage requirement pertaining to election statements, plans of care,
p1'vision of  services, and certification ofterminal illness.
OIG Recommendation
Educate hospices about the coverage requirements and their impo11ance in ensuring quality of
care.
CMS Response
The Centers for Medicare & Medicaid Services (CMS) concurs with this recommendation,
When ejecting the Medicare hospice benefit, a Medicare beneficiary waives his/her right to have
Medicare pay for services related to the treatment of the terminal condition for which hospice
was elected (or a related condition), except when provided or  arranged for by the Medicare
hospice. Therefore, it is critically important that Medicare beneficiaries are certified
appropriately and understand the implications of electing to receive hospice care.
o EI. 02.06. 00 221 MEDICARE HOSPICE CARE FOR BENEFICIARIES IN NURSING FACILITIES: COMPLIANCE WITH 23
MEDICARE COVERAGE REQUIREMENTS  
   
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 A C K N O W L E D G M E N T S  
 
This report was prepared under the direction of Jodi Nudelman, 
Regional Inspector General for Evaluation and Inspections in the  
New York regional office, and Meridith Seife, Deputy Regional Inspector 
General.   
Nancy Harrison served as the team leader for this study.  Other 
principal Office of Evaluation and Inspections staff from the New York 
regional office who contributed to the report include Olivia Herman, 
Michelle McInnis, and Bailey Orshan; central office staff who 
contributed include Rob Gibbons and Sandy Khoury.  
 
  OEI-02-06-00221  MEDICARE HOSPICE CARE FOR BENEFICIARIES IN NURSING FACILITIES:  COMPLIANCE WITH    27 
    MEDICARE COVERAGE REQUIREMENTS