Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
H S I
O SPICES  HOULD  MPROVE 
 
T E S
HEIR  LECTION  TATEMENTS 
 
 
C
AND  ERTIFICATIONS OF 
 
 
T I  
ERMINAL  LLNESS 
 
 
 
Suzanne Murrin 
Deputy Inspector General for 
Evaluation and Inspections 
 
September 2016 
OEI-02-10-00492  Report  in  Brief    
   
September  2016  
Report  No.  OEI021000492  
 
 
Why  OIG  Did  This  Review    Hospices  Should  Improve  Their  Election  
Medicare  hospice  care  is  intended  to   Statements  and  Certifications  of  Terminal  
help  terminally  ill  beneficiaries  
Illness  
continue  life  with  minimal   Key  Takeaway 
disruptions  and  to  support  
beneficiaries  families.   Two  key   What  OIG  Found   It  is  important  that  hospices  
provide  complete  and  accurate  
requirements  of  the  benefit  are  for   We  found  that  hospice  election  statements  
information  in  election  
the  beneficiary  to  sign  an  election   lacked  required  information  or  had  other  
statements  so  that  beneficiaries  
statement  and  for  a  physician  to   vulnerabilities  in  more  than  onethird  of   and  caregivers  can  make  
certify  the  beneficiary  as  terminally   general  inpatient  care  (GIP)  stays.   Notably,   informed  care  choices.   It  is  also  
ill.   These  requirements  provide   they  did  not  always  mentionas  required  critical  that  physicians  fulfill  
critical  safeguards  to  ensure  that  the   that  the  beneficiary  was  waiving  coverage  of   their  role  and  complete  
beneficiary  understands  the  benefit   certain  Medicare  services  by  electing  hospice   certifications  of  terminal  illness  
and  that  the  physician  is  involved  in   care  or  that  hospice  care  is  palliative  rather   as  required.   These  certifications 
are  an  important  safeguard  in  
determining  whether  the  beneficiary   than  curative.   Further,  in  14  percent  of  GIP  
ensuring  that  beneficiaries  are  
is  appropriate  for  hospice  care.    stays,  the  physician  did  not  meet  
appropriately  receiving  hospice  
requirementssuch  as  composing  a  
Previous  OIG  work  has  raised   care. 
narrativewhen  certifying  that  the  
concerns  that  some  election  
beneficiary  was  terminally  ill  and  appeared  to   However,  we  identified  
statements  used  by  hospices  are   concerns  with  election  
have  limited  involvement  in  determining  that  
misleading  and  that  physicians  are   statements  in  more  than  one
the  beneficiary  was  appropriate  for  hospice  
sometimes  not  involved  in  care   third  of  hospice  GIP  stays  and,  
care.   
planning  and  may  rarely  see   in  14  percent  of  stays,  the  
beneficiaries.   Also,  OIG  has   What  OIG  Recommends  and  Agency   physician  did  not  meet  
requirements  when  certifying.   
investigated  numerous  cases  in  which   Response    
hospices  submitted  fraudulent  claims   The  findings  in  this  report  make  clear  that  
for  patients  who  were  not   hospices  should  improve  their  election  statements  and  ensure  that  
appropriate  for  hospice  care.   physicians  meet  requirements  when  certifying  beneficiaries  for  
hospice  care.  
How  OIG  Did  This  Review  
We  based  this  study  on  a  review  of   We  recommend  that  the  Centers  for  Medicare  &  Medicaid  Services  
hospice  election  statements  and   (CMS)  (1)  develop  and  disseminate  model  text  for  election  
certifications  of  terminal  illness  from   statements,  (2)  instruct  surveyors  to  strengthen  their  review  of  
a  stratified  random  sample  of  hospice  
election  statements  and  certifications  of  terminal  illness,  (3)  
general  inpatient  (GIP)  stays  in  2012.   
educate  hospices  about  election  statements  and  certifications  of  
Although  the  election  statements  and  
terminal  illness,  and  (4)  provide  guidance  to  hospices  regarding  the  
certifications  of  terminal  illness  were  
effects  on  beneficiaries  when  they  revoke  their  election  and  when  
collected  for  a  previous  OIG  study  
they  are  discharged  from  hospice  care.  
that  focused  on  GIP,  these  
documents  are  for  the  hospice  
CMS  concurred  with  three  of  our  recommendations  and  neither  
benefit  as  a  whole  and  are  not  
concurred  nor  nonconcurred  with  the  fourth  recommendation.  
specific  to  any  one  level  of  care.  
   
 
Full  report  can  be  found  at  http://oig.hhs.gov/oei/reports/oei021000492.asp    
   
 
TABLE OF CONTENTS 
 
Objectives .................................................................................................... 1 
Background ................................................................................................. 1 
Methodology ............................................................................................... 5 
Findings ....................................................................................................... 7 
In more than one-third of GIP stays, hospice election statements 
lacked required information or had other vulnerabilities ................ 7 
In many cases, hospices included information in election statements 
that is not required ......................................................................... 10 
In 14 percent of GIP stays, the physician did not meet   
requirements when certifying and appeared to have limited 
involvement in determining that the beneficiary was appropriate   
for hospice care ............................................................................. 11 
Conclusion and Recommendations ........................................................... 12 
            Agency Comments and OIG Response ......................................... 15 
Appendixes ................................................................................................ 16 
A:  Levels of Care and Payment Rates .......................................... 16 
B:  Detailed Methodology ............................................................. 17 
C:  Statistical Estimates and Confidence Intervals ........................ 19 
D:  Agency Comments .................................................................. 21 
              Acknowledgments ..................................................................................... 24
   
 
 
 
 
 
   
   
OBJECTIVES 
1.  To determine the extent to which hospice election statements lack 
required information or have other vulnerabilities. 
2.  To determine the extent to which physicians meet requirements when 
certifying beneficiaries for hospice care. 
BACKGROUND 
The goals of hospice care are to help terminally ill beneficiaries continue 
life with minimal disruption and to support their families and other 
caregivers.  In 2013, Medicare paid $15.1 billion for hospice care for  
1.3 million beneficiaries.1 
Two key requirements of the Medicare hospice benefit are for the 
beneficiary to elect hospice care and for a physician to certify that the 
beneficiary is terminally ill.  When electing hospice care, the beneficiary 
signs an election statement that is written by the hospice.  The election 
statement is intended to ensure that the beneficiary understands the hospice 
benefitparticularly that hospice care is palliative, not curativeand that 
the beneficiary waives the right to Medicare payment for treatment of the 
terminal illness except for services provided by the hospice.2  At the 
beginning of care and at set intervals thereafter, a physician completes 
a certification of terminal illness, which is intended to ensure that the 
physician is involved in determining whether the beneficiary is appropriate 
for hospice care.   
Previous OIG work has raised concerns that some election statements used 
by hospices are misleading and that physicians are sometimes not involved 
in care planning and may rarely visit beneficiaries.3  In addition, OIG has 
investigated a number of recent hospice fraud cases that illustrate the need 
to focus on program integrity.  For example, in one case, the owner of a 
hospice in Mississippi used patient recruiters and submitted fraudulent 
                                                                                                                           
1 Medicare Payment Advisory Commission (MedPAC), Report to Congress:  Medicare 
Payment Policy, March 2015, ch. 12, p. 285.  Accessed at http://medpac.gov/documents/ 
reports/mar2015_entirereport_revised.pdf?sfvrsn=0 on May 11, 2015. 
2 42 CFR  418.24.  Services may be made under arrangements by the hospice or provided 
by the beneficiarys attending physician. 
3 For concerns about election statements, see OIG, Medicare Hospice Care for 
Beneficiaries in Nursing Facilities:  Compliance With Medicare Coverage Requirements 
(OEI-02-06-000221), September 2009.  For concerns about physician involvement see 
OIG, Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living 
Facilities (OEI-02-14-00070), January 2015; and OIG, Hospices Inappropriately Billed 
Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491), March 2016. 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  1   
   
claims to Medicare for patients who were not appropriate for 
hospice.  According to investigators, these beneficiaries had no idea they 
were in hospice care.  The owner was sentenced to 3 years in prison and 
ordered to pay $1.1 million in restitution to Medicare.4 
In another case, a hospice in Philadelphia submitted false claims to 
Medicare and altered patient records to make patients appear to be eligible 
for hospice services when they were not.  To increase enrollment, the 
hospice owner also paid health care professionals for referring patients to 
his hospice even though they were not appropriate for hospice care.  The 
owner was found guilty of health care fraud and sentenced to more than  
14 years in prison and ordered to pay $16.2 million in restitution to 
Medicare.5 
Also in Pennsylvania, a hospices former chief operating officer admitted 
that she caused her staff to put patients in hospice care who were not 
appropriate for the benefit.  She faces a possible 10-year sentence for health 
care fraud.6 
These cases demonstrate the importance of having key safeguards in place 
that keep beneficiaries well informed and help ensure that the hospice care 
provided to beneficiaries is appropriate.    
The Medicare Hospice Benefit 
To be eligible for Medicare hospice care, a beneficiary must be entitled to 
Part A of Medicare and be certified as having a terminal illness with a life 
expectancy of 6 months or less if the disease runs its normal course.7  Upon 
a beneficiarys election of hospice care, the hospice agency is responsible 
for medical care related to the beneficiarys terminal illness and related 
conditions.  Beneficiaries who elect hospice care are entitled to receive care 
for two 90-day periods, followed by an unlimited number of 60-day 
                                                                                                                           
4 Department of Justice (DOJ), Cleveland Woman Sentenced for Hospice Fraud, 
December 4, 2015.  Accessed at https://www.justice.gov/usao-ndms/pr/cleveland-woman-
sentenced-hospice-fraud on June 17, 2016. 
5 DOJ, Hospice Owner Sentenced To More Than 14 Years For Health Care Fraud 
Scheme, May 27, 2014.  Accessed at https://www.justice.gov/usao-edpa/pr/hospice-
owner-sentenced-more-14-years-health-care-fraud-scheme on June 17, 2016. 
6 DOJ, Former Horizons Hospice Chief Operating Officer Pleads Guilty to Health Care 
Fraud, June 2, 2016.  Accessed at https://www.justice.gov/usao-wdpa/pr/former-
horizons-hospice-chief-operating-officer-pleads-guilty-health-care-fraud on June 17, 2016. 
7 Social Security Act,  1814(a)(7)(A) and 1861(dd)(3)(A), 42 U.S.C.  1395f(a)(7)(A) 
and 1395x(dd)(3)(A); 42 CFR  418.20 and 418.22.  Certification is based on the 
physicians or medical directors clinical judgment regarding the normal course of the 
individuals illness.   
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  2   
   
periods.8  These periods are known as election periods and need not be 
consecutive. 
Hospice care includes nursing care, medical social services, medical 
supplies (including drugs and biologicals), and physician services, among 
other things.  By electing hospice care, the beneficiary waives all rights to 
Medicare payment for services related to the treatment of the terminal 
illness and related conditions except for services provided by or arranged 
for by the hospice.  The beneficiary retains rights to Medicare payment for 
services to treat conditions unrelated to the terminal illness.9  
The Medicare hospice benefit has four levels of care, which are paid at 
different rates.  The levels are routine home care, general inpatient care 
(GIP), continuous home care, and inpatient respite care.10  GIP is the second 
most expensive and, next to routine home care, is the most commonly used.  
GIP is provided in a hospice inpatient unit, a hospital, or a skilled nursing 
facility for symptom management or pain control that cannot be managed 
in other settings.11  See Appendix A for descriptions of the levels of care 
and payment rates.   
Election of Hospice Care 
A beneficiary choosing Medicare hospice care must file an election 
statement with a hospice.  This statement is designed by the hospice and 
signed by the beneficiary.  Regulations require that the election statement 
include information on key features of the hospice benefit.  Specifically, the 
election statement must include acknowledgments that the beneficiary 
(1) has been given a full understanding of the palliative rather than curative 
nature of hospice care and (2) is waiving all rights to Medicare payment for 
certain servicessuch as treatment of the terminal illness and related 
conditionswhen not provided by or arranged for by the beneficiarys 
designated hospice.12  
                                                                                                                           
8 Social Security Act,  1812(a)(4), 42 U.S.C.  1395d(a)(4).  Prior to 1990, Medicare 
provided hospice coverage for a maximum of 210 days.   
9 Social Security Act,  1812(d)(2)(A) and 1861(dd)(1), 42 U.S.C.  1395d(d)(2)(A) 
and 1395x(dd)(1); 42 CFR  418.24(d).  CMS has developed the Medicare Care Choices 
Model, a demonstration program that will allow certain beneficiaries to receive palliative 
care services from certain hospice providers while concurrently receiving services 
provided by their curative care providers.  The model will enable CMS to study whether 
access to such services improves quality of life, increases patient satisfaction, and reduces 
Medicare expenditures.  See CMS, Medicare Care Choice Model.  Accessed at 
http://innovation.cms.gov/initiatives/Medicare-Care-Choices/ on January 26, 2016. 
10 42 CFR  418.302. 
11 42 CFR  418.108(a) and 418.302(b)(4). 
12 42 CFR  418.24(b) and (d).  Other requirements include the identification of the 
hospice, the effective date of election, and the signature of the individual or representative.   
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  3   
   
A beneficiary may revoke his or her election of hospice care and return to 
standard Medicare coverage at any time.  To do so, the beneficiary must 
provide the hospice with a signed statement.13   
A hospice may discharge a beneficiary if the beneficiary moves out of the 
hospices service area, transfers to another hospice, or is no longer 
terminally ill.  A hospice can also discharge a beneficiary for cause.14 
Certification of Terminal Illness 
At the beginning of each election period, at least one physician must certify 
that the beneficiary is terminally ill with a life expectancy of 6 months or 
less.15  The certification of terminal illness must be based on the physicians 
clinical judgment regarding the normal course of the beneficiarys illness 
and must be supported by clinical information in the medical record.   
The physician must include a narrative in the certification that explains the 
clinical findings.  It must reflect the beneficiarys individual clinical 
circumstances and cannot include checkboxes or standard language used 
for all patients.16  The narrative must include an attestation confirming that 
the physician wrote the narrative based on either an examination of the 
patient or a review of the clinical record.17  For the third and subsequent 
periods, the beneficiary must be examined face-to-face by either 
a physician or a nurse practitioner.18   
CMS Oversight 
Hospices must be certified to participate in the Medicare program.19  In 
2013, there were 3,925 Medicare hospices.  Of these, 2,411 were for-profit, 
1,314 were nonprofit, and 200 were government-owned.20 
                                                                                                                           
13 Social Security Act,  1812(d)(2)(B), 42 U.S.C.  1395d(d)(2)(B); 42 CFR  418.28. 
14 A hospice can discharge a beneficiary for cause if a beneficiarys behavior is disruptive, 
abusive, or uncooperative to the extent that delivery of care to the beneficiary or the ability 
of the hospice to operate effectively is seriously impaired.  See 42 CFR  418.26(a). 
15 The initial certification must be done by the medical director of the hospice or the 
physician member of the hospice interdisciplinary group and the beneficiarys attending 
physician, if the beneficiary has one.  Subsequent certifications can be done by one 
physician.  See 42 CFR  418.22(c). The attending physician is a physician or nurse 
practitioner identified by the beneficiary as having the most significant role in the 
beneficiarys medical care.  See 42 CFR  418.3. 
16 42 CFR  418.22(b)(3)(iv). 
17 42 CFR  418.22(b)(3)(iii). 
18 42 CFR  418.22(a)(4). 
19 Social Security Act,  1814(a) and 1866, 42 U.S.C.  1395f(a) and 1395cc. 
20 Medicare Payment Advisory Commission (MedPAC), Report to Congress:  Medicare 
Payment Policy, March 2015, ch. 12, p. 296.  Accessed at 
http://medpac.gov/documents/reports/mar2015_entirereport_revised.pdf?sfvrsn=0 on 
May 11, 2015. 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  4   
   
CMS contracts with State survey and certification agencies to conduct 
onsite surveys of hospices at the time of initial hospice certification, for 
recertification, and in response to complaints.  These surveys determine 
whether the hospice meets Medicare requirements.21  Surveyors review a 
sample of beneficiaries records during this process, including the election 
statements and certifications of terminal illness.22  Surveyors must cite 
deficiencies when hospices fail to meet requirements.   
Related Work 
This report is part of a larger body of OIG work examining the delivery of 
hospice care to Medicare beneficiaries.  A recent OIG report found that 
hospices billed one-third of GIP stays inappropriately, costing Medicare 
$268 million in 2012.23  Hospices sometimes provided poor-quality care 
and often did not provide intense services.  Another OIG report found that 
hospices typically provided fewer than 5 hours of visits per week and were 
paid about $1,100 per week for each beneficiary receiving routine home 
care in assisted living facilities.24  It also found that hospice physicians 
rarely saw beneficiaries who received care in assisted living facilities.   
METHODOLOGY 
We based this study on a review of hospice election statements and 
certifications of terminal illness from a stratified random sample of 
565 GIP stays in 2012.  The sample was selected for another OIG study, 
which focused on the use of GIP.25  However, the election statements and 
certifications of terminal illness that hospices use are for the hospice 
benefit as a whole and are not specific to any one level of care. 
We reviewed the election statements for key required features, such as 
information about the palliative nature of hospice care and the waiver of 
coverage for certain services.  We also noted when statements contained 
inaccurate information and when they contained information beyond what 
is required.  We reviewed the certifications of terminal illness for key 
information, focusing on the physician narratives and attestations. 
                                                                                                                           
21 National accreditation organizations may perform the certification and recertification 
process for some hospices in accordance with section 1865 of the Social Security Act. 
22 CMS, State Operations Manual, Appendix M - Guidance to Surveyors:  Hospice, 
Accessed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ 
Downloads/som107ap_m_hospice.pdf on June 19, 2015. 
23 OIG, Hospices Inappropriately Billed Medicare Over $250 Million for General 
Inpatient Care (OEI-02-10-00491), March 2016. 
24 OIG, Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living 
Facilities (OEI-02-14-00070), January 2015. 
25 OIG, Hospice Inappropriately Billed Medicare Over $250 Million for General Inpatient 
Care (OEI-02-10-00491), March 2016. 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  5   
   
See Appendix B for more detailed information about the methodology.  See 
Appendix C for all statistical estimates and 95-percent confidence intervals.  
Limitations 
For this study, we reviewed the content of hospice election statements and 
certifications of terminal illness.  We did not 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 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  6   
   
FINDINGS 
In more than one-third of GIP stays, hospice election 
statements lacked required information or had other 
vulnerabilities 
Before receiving hospice care, a beneficiary signs an election statement that 
has been written by the hospice.  Complete and accurate election statements 
are an important safeguard to ensure that beneficiaries and their caregivers 
can make informed decisions about their care and understand what they are 
getting and what they are giving up when they elect hospice care.  However, 
in 35 percent of GIP stays, hospices used election statements that were 
missing required information or had other vulnerabilities.  See Table 1. 
 
  Table 1:  Percentage of GIP Stays With Election Statements That Lacked 
  Required Information or Had Other Vulnerabilities  
Vulnerability With Election Statement *  Percentage of GIP Stays  
Did not specify Medicare                        19% 
Required waiver information was missing or was stated inaccurately  12% 
Required information about palliative care was missing                  9% 
Revocation or discharge information was inaccurate or unclear  4% 
*Categories are not mutually exclusive. 
Source:  OIG analysis of election statements, 2015. 
In 19 percent of GIP stays, the election statements did not specify that the 
hospice benefit that the beneficiary was electing was Medicare hospice.  
These statements either referred to Medicaid hospice or referred to another 
hospice benefit in addition to Medicare, such as private health insurance, and 
did not indicate which hospice benefit the beneficiary was electing.  
Statements that do not make clear that the election is for Medicare hospice 
care are depriving beneficiaries of critical information.  It is important for 
beneficiaries to know which benefit they are receiving, especially because 
eligibility criteria and election periods in some State Medicaid programs 
differ from those in Medicare, and private health insurance may cover 
hospice care very differently than Medicare.   
In 12 percent of stays, the election statements did not mentionas 
requiredthat the beneficiary was waiving coverage of certain Medicare 
services by electing hospice care, or inaccurately stated what Medicare 
benefits were waived.  For example, some election statements stated that the 
beneficiary waived the right to all other benefits under the Medicare program 
while receiving hospice benefits.  This is not accurate.  A beneficiary who 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  7   
   
elects hospice care retains rights to Medicare payment for services to treat 
conditions unrelated to the terminal illness.  
In 9 percent of stays, the election statements did not stateas requiredthat 
hospice care is palliative, rather than curative.  Palliative care means patient- 
and family-centered care that optimizes the quality of life by anticipating, 
preventing, and treating suffering.26  Election statements must include the 
beneficiarys acknowledgment that he or she has been given a full 
understanding of this type of care. 
In 4 percent of stays, the election statements included inaccurate or unclear 
information about how a beneficiary may revoke the election of hospice care 
or how the hospice may discharge a beneficiary.  See the example of such a 
statement in the box on the following page.  Information on revocation and 
discharge is not a required feature of election statements, but hospices may 
include such information.  Beneficiaries who are given inaccurate or unclear 
information may not understand their rights and might be at a disadvantage if 
disagreements arise with their hospices.   
In addition, hospices provided inconsistent information about the effect of 
revocation and discharge on the beneficiary.  While some election statements 
explained that both revocation and discharge result in the beneficiary's losing 
the remaining days in the election period, others said this only about 
revocation.  Also, many election statements did not say when a beneficiary 
who is eligible can again elect the hospice benefit after revocation or 
discharge.   
Hospices inconsistencies in their election statements may stem from the 
way revocation and discharge are discussed in statute, regulations, and the 
CMS manual.  The three sources note that upon revocation, a beneficiary is 
no longer covered under the Medicare hospice benefit for the remainder of 
the election period. 27  They also mention that the beneficiary may elect to 
receive hospice coverage in another election period. 28  However, it is unclear 
                                                                                                                           
26 42 CFR  418.3. 
27 Social Security Act,  1812(d)(2)(B)(i), 42 U.S.C.  1395d(d)(2)(B)(i); 42 CFR  
 418.28(c)(1); CMS, Medicare Benefit Policy Manual, ch. 9,  20.2.2 (Rev. 209, effective 
10/1/14).  
28 Social Security Act,  1812(d)(2)(B)(ii), 42 U.S.C.  1395d(d)(2)(B)(ii); 42 CFR  
 418.24(e) and 418.28(c)(3); CMS, Medicare Benefit Policy Manual, ch. 9,  20.2.2 
(Rev. 209, effective 10/1/14).   
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  8   
   
whether the beneficiary can start a subsequent election period immediately or 
only after the remaining days of the election period have passed. 29   
In addition, the regulations and manual discuss discharge differently.  The 
manual explicitly states that upon discharge, the beneficiary loses the 
remaining days in the election period; the regulations do not address whether 
the beneficiary loses the remaining days in the election period.30  As with 
revocation, it is unclear when a beneficiary can again obtain hospice 
coverage after discharge.  The regulations and manual do not clarify whether 
the beneficiary can reelect hospice immediately or only once the remaining 
days in the current election period have passed.  
 
 
 
Example of Inaccurate Information Contained in Election Statements 
 
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. 
 
  Contrary to this statement, a beneficiary does not revoke the hospice 
election or get automatically discharged simply by choosing care without 
authorization.  To revoke the election, the beneficiary must provide the 
hospice with a signed statement. 31  A hospice may discharge a beneficiary 
if the beneficiary moves out of the service area or transfers to another 
hospice, if the hospice determines that the beneficiary is no longer 
terminally ill, or for cause.  To discharge a beneficiary for cause, the 
hospice must follow a number of steps, including informing the 
beneficiary that he or she might be discharged and making a serious effort 
to resolve the problem. 32 
 
 
Some election statements had other features that might confuse beneficiaries.  
For instance, some hospices included the election statement within a much 
longer and more complex document or labeled the election statement 
something other than election, such as Admission Service Agreement or 
Financial Agreement.  Other hospices used small print for the text 
explaining the palliative nature of hospice care, which may make it difficult 
for some beneficiaries and caregivers to read. 
                                                                                                                           
29 Election periods are a set number of days consistently defined as two initial periods of 
90 days each and an unlimited number of subsequent periods of 60 days each.  Social 
Security Act,  1812(a)(4) and 1812(d)(1), 42 U.S.C.  1395d(a)(4) and 1395d(d)(1);  
42 CFR  418.21; and CMS, Medicare Benefit Policy Manual, ch. 9,  10 (Rev. 188, 
effective 8/4/14).   
30 42  CFR 418.26(c); CMS, Medicare Benefit Policy Manual, ch. 9,  20.2.3 (Rev. 209, 
effective 10/1/14).  The Social Security Act does not mention discharge at all. 
31 42 CFR  418.28(b). 
32 42 CFR  418.26(a)(3). 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  9   
   
In many cases, hospices included information in 
election statements that is not required 
Although they are not required to do so, many hospices added detailed 
information to their election statements that explained key parts of the 
hospice benefit.  For example, information about potential costs to the 
beneficiarysuch as coinsurance payments for drugs or for the inpatient 
respite level of carewas included in the election statements for 
approximately two-thirds of GIP stays.  
Information about the lengths of hospice election periods was included in the 
election statements for almost two-thirds of GIP stays.  In addition, election 
statements for almost half of GIP stays noted that the beneficiary can change 
hospice providers, although not all of the statements explained that it could 
be done just once per election period.  Some statements included other 
information, such as the levels of hospice care available and specific services 
that the hospice provides, such as nursing and hospice aide services.   
Election statements for almost a third of stays noted that hospice services 
were available 24 hours a day, 7 days a week.  This may be especially 
important because previous OIG work found that hospices often provided far 
fewer services on weekends than on weekdays, and beneficiaries and their 
caregivers may not know that hospices are required to make needed services 
available on a 24-hour basis.33  A few statements also included a 24-hour 
phone number to call with any questions.  See Figure 1.   
 
Figure 1:  Percentage of GIP Stays with Election Statements That Contained 
Selected Additional Information 
 
0% 10% 20% 30% 40% 50% 60% 70% 80%
   
Potential costs to beneficiaries 67%
Benefit periods 64%
Ability to change hospice 48%
Levels of hospice care 48%
Services provided 42%
Availability of services 24/7 31%
Source:  OIG analysis of election statements, 2015. 
                                                                                                                           
33 OIG, Medicare Hospices Have Financial Incentives to Provide Care in Assisted Living 
Facilities (OEI-02-14-00070), January 2015.  See also 42 CFR  418.100(c)(2). 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  10   
   
Other features that were not as commonly found, but may be helpful, 
included text in large print sizes; instructions directing the beneficiary or 
representative to initial the sections of the statement that contain important 
facts about the benefit; contact information for Medicare; and information 
on how to make a complaint. 
 
In 14 percent of GIP stays, the physician did not meet 
requirements when certifying and appeared to have 
limited involvement in determining that the beneficiary 
was appropriate for hospice care  
 
To be eligible for hospice care, a beneficiary must be certified as terminally 
ill with a life expectancy of 6 months or less.  This is done by a physician for 
every election period and is based on the physicians clinical judgment.34  
Certifying physicians are required to compose a narrative and include an 
attestation in each certification of terminal illness.  These requirements help 
to ensure that physicians are involved in determining that the beneficiary has 
a life expectancy of 6 months or less and is appropriate for hospice care.  
 
However, in 14 percent of GIP stays, the certifying physician did not meet at 
least one of these requirements.  Specifically, in 10 percent of stays, the 
certifying physician did not include a narrative at all or included only the 
beneficiarys diagnosis.  This means that the certifying physician did not 
explain the clinical findings that support a life expectancy for the beneficiary 
of 6 months or less.  In one example, the physician merely wrote, resp. 
failure dying.  This is in sharp contrast to other narratives that provided 
details about the beneficiarys condition, such as the beneficiarys activities 
of daily living, weight loss, moods, body mass index, and changes in scores 
on the palliative performance scale. 
 
In 5 percent of GIP stays, the certifying physician did not include an 
attestation.35  That is, the physician did not attest that the narrative was based 
on his or her examination of the beneficiary or review of the medical records.  
Composing a narrative and attesting that the narrative was based on an 
examination or record review are important safeguards to ensure that 
certifying physicians fulfill their role and demonstrate active involvement in 
the certifying process.   
 
   
                                                                                                                           
34 42 CFR  418.22(b). 
35 Some election statements lacked both a narrative and an attestation. 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  11   
   
CONCLUSION AND RECOMMENDATIONS 
This report looks at two key coverage requirements for the Medicare 
hospice benefit:  election statements and certifications of terminal illness.  
It is part of a larger body of work that has revealed numerous 
vulnerabilities and raised serious questions about how the benefit is 
administered, such as whether Medicare is paying appropriately for hospice 
care and whether beneficiaries are receiving the services they need in their 
last months of life.  These questions highlight both the need to protect the 
integrity of the hospice benefit and the need to protect beneficiaries. 
The findings in this report make clear that hospices should improve their 
election statements and ensure that physicians meet requirements when 
certifying beneficiaries for hospice care.  In 35 percent of GIP stays, 
hospices election statements lacked required information or had other 
vulnerabilities.  It is essential that hospices provide beneficiaries and their 
caregivers with accurate and complete information, especially about the 
palliative nature of hospice care and the benefits they are waiving.  This is 
critical to ensuring that beneficiaries and their caregivers make informed care 
choices, especially because beneficiaries who elect hospice care arein 
essenceturning over all care for their terminal illness to the hospice.   
In 14 percent of GIP stays, the certifying physician did not meet 
requirements and appeared to have limited involvement in determining that 
the beneficiary was appropriate for hospice care.  It is essential that 
physicians fulfill their role and complete certifications as required, as these 
certifications are a critical safeguard in ensuring that beneficiaries are 
appropriately receiving hospice care. 
We recommend that CMS:  
Develop and disseminate model text for election statements  
CMS should develop model text that hospices could use in crafting their 
election statements.  This might be done through CMS contractors, such as 
the Medicare Administrative Contractors that oversee the hospice benefit.  
Model text will help ensure that hospice election statements are clear and 
complete and that they contain accurate information about the Medicare 
hospice benefit.   
The model text should clearly identify the benefit as Medicare, as we found 
numerous instances in which the election statement does not.  Medicare can 
have different rules than other payers, so it is important for beneficiaries to 
know that Medicare, as opposed to other payers, is covering their care. This 
is a fundamental program integrity safeguard.  The statement must clearly 
communicate to beneficiaries and their families which program is paying for 
beneficiaries care, especially so that they know which program to contact if 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  12   
   
they experience problems with the hospice or have any questions about 
which services they are entitled to receive.  
The model text should also accurately explain what the beneficiary is 
waiving and describe the palliative nature of hospice care.  In addition, the 
model text should include helpful information about the hospice benefit, so 
that hospices can choose to add this information to their election statements.  
Specifically, the model text should include information about services being 
available 24 hours a day, an explanation of services included in the benefit, 
and contact information for the hospice. 
Instruct surveyors to strengthen their review of election 
statements and certifications of terminal illness 
CMS should instruct surveyors toas a part of the survey and certification 
processincrease their attention to the requirements for election statements.  
Surveyors should determine whether election statements contain all the 
required information and that this information is accurate.  If not, surveyors 
should cite deficiencies.  Likewise, surveyors should strengthen their review 
of certifications of terminal illness to ensure that certifying physicians are 
meeting the requirements.  Surveyors should cite deficiencies when they find 
certifications that are not complete.  Surveyors should strengthen their 
reviews of all hospices but should particularly focus on the hospices we 
found to have election statements that lacked required information or had 
other vulnerabilities and on the hospices that had certifications for which the 
physician did not meet requirements.  We will provide a list of these hospices 
to CMS in a separate memorandum.   
Educate hospices about election statements and certifications 
of terminal illness 
CMS should provide training to hospice providers about the requirements for 
election statements.  The model text that we recommend be developed could 
serve as a basis for part of this training.  The training should reiterate the 
requirements and ensure that hospices are reviewing and revising their 
election statements as appropriate.  CMS should also provide training to 
hospices about the requirements for certifications of terminal illness.  In 
addition, CMS should work with hospices to educate physicians about their 
responsibilities in determining and documenting their clinical findings for 
certifying terminal illness, given the important role that certifying physicians 
play in ensuring the appropriate use of hospice care.  As part of this effort, 
CMS could develop educational materials that hospices can share with 
physicians.  CMS should educate all hospices but should particularly focus 
on the hospices we found to have election statements that lacked required 
information or had other vulnerabilities and on the hospices that had 
certifications for which the physician did not meet requirements.  We will 
provide a list of these hospices to CMS in a separate memorandum.   
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  13   
   
Provide guidance to hospices regarding the effects on 
beneficiaries when they revoke their election and when they are 
discharged from hospice care  
CMS should provide guidance to hospices that clarifies the effects of 
revocation and discharge on the beneficiary.  This guidance should explicitly 
address (1) whether remaining days of the election period are lost and  
(2) when, after revocation or discharge, a new election period can begin for 
beneficiaries who are eligible.  Hospices should have a clear understanding 
of the effects of revocation and discharge so that they can consistently 
implement policies and accurately inform beneficiaries.     
 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  14   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
 
CMS concurred with three of our recommendations and neither concurred 
nor nonconcurred with the fourth recommendation.  
CMS concurred with our first recommendation to develop and disseminate 
model text for election statements.  CMS stated that it will develop model 
text that satisfies the regulatory requirements, which could be used by 
hospices when designing their own election statements. 
CMS concurred with our second recommendation to instruct surveyors to 
strengthen their review of election statements and certifications of terminal 
illness.  CMS stated that it will revise the Basic Hospice Training provided 
to surveyors to place appropriate emphasis on election statements and 
certifications of terminal illness.  CMS will also include these topics during 
yearly training and webinars with surveyors. 
CMS concurred with our third recommendation to educate hospices about 
election statements and certifications of terminal illness.  CMS stated that, 
together with the Medicare Administrative Contractors, it will work to 
issue guidance to providers on election statements and certifications of 
terminal illness.  CMS will also continue to use the Medicare Learning 
Network, weekly electronic newsletters and quarterly compliance 
newsletters to educate providers on avoiding common errors. 
CMS neither concurred nor nonconcurred with our fourth recommendation 
to provide guidance to hospices regarding the effects on beneficiaries when 
they revoke their election and when they are discharged from hospice care.  
CMS stated that it will monitor patient revocations and discharges and 
provide additional guidance to hospices, if needed.  OIG reiterates the need 
for clearer guidance regarding the effects of revocation and discharge, as 
hospices have provided inconsistent information about the effect of 
revocation and discharge on the beneficiary.  The statute, regulations, and 
the CMS manual note that upon revocation, a beneficiary is no longer 
covered under the Medicare hospice benefit for the remainder of the 
election period.  They also mention that the beneficiary may elect to 
receive hospice coverage in another election period.  However, it is unclear 
whether the beneficiary can start a subsequent election period immediately 
or only after the remaining days of the election period have passed.  
Similarly, it is unclear when a beneficiary can again obtain hospice 
coverage after discharge.  The regulations and CMS manual do not clarify 
whether the beneficiary can reelect hospice immediately or only once the 
remaining days in the current election period have passed. 
For the full text of CMSs comments, see Appendix D. 
   
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  15   
   
APPENDIX A 
Levels of Care and Payment Rates 
The Medicare hospice benefit has four levels of care: routine home care, 
general inpatient care (GIP), continuous home care, and inpatient respite 
care.  Routine home care is the most commonly used, followed by GIP.  
GIP is provided in a hospice inpatient unit, a hospital, or a skilled nursing 
facility.36  It is for pain control or symptom management that cannot be 
managed in other settings, such as the beneficiarys home.37  Continuous 
home care is allowed only during brief periods of crisis and only as 
necessary to maintain the individual at home.38  Inpatient respite care is 
short-term inpatient care provided to the beneficiary when necessary to 
relieve the beneficiarys caregiver.39 
Medicare pays hospices a daily rate from the day a beneficiary elects 
hospice care to the day of discharge.  Each level of hospice care has an 
all-inclusive daily rate that is paid through Part A.40  The daily rate is paid 
to the hospice for each day that a beneficiary is in hospice care, regardless 
of the amount of services furnished on a particular day.  The rates are 
adjusted on the basis of the beneficiarys geographic location.  See 
Table A-1 for the unadjusted payment rates for each level of care in fiscal 
year (FY) 2015.  Beneficiaries generally do not pay coinsurance for 
hospice care.41 
Table A-1:  Unadjusted Daily Medicare Hospice Payment 
Rates by Level of Care, FY 2015 
Routine Home Care  $159.34  
Continuous Home Care  $929.91  
General Inpatient Care  $708.77  
Inpatient Respite Care  $164.81  
Source:  CMS, Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index, 
Quality Reporting Program and the Hospice Pricer for FY 2015, Transmittal R3023CP, 
Change Request 8876, October 1, 2014.  
 
                                                                                                                           
36 42 CFR  418.108(a).   
37 42 CFR  418.302(b)(4). 
38 42 CFR  418.302(b)(2); 42 CFR  418.204(a)(defining periods of crisis); and CMS, 
Medicare Claims Processing Manual, Pub. 100-04, ch. 11,  30.1. 
39 42 CFR  418.302(b)(3). 
40 For continuous home care, the hospice is paid an hourly rate based on the number of 
hours of continuous care furnished to the beneficiary on that day.  The daily continuous 
home care rate is divided by 24 hours to determine an hourly rate.  A minimum of 8 hours 
of predominantly nursing care must be provided.  CMS, Medicare Claims Processing 
Manual, Pub. 100-04, ch. 11,  30.1.   
41 Hospices may charge beneficiaries a 5-percent coinsurance for inpatient respite care. 
Hospices also may charge beneficiaries a coinsurance payment, not exceeding $5, for each 
palliative drug and biological prescription. See 42 CFR  418.400. 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  16   
   
APPENDIX B 
Detailed Methodology 
Selection of Statistical Sample 
We based this study on a review of election statements and certifications of 
terminal illness from a stratified random sample of GIP stays.  The sample 
was selected for another OIG study, which focused on the use of GIP. 42  As 
part of that study, we collected the election statements and certifications of 
terminal illness for the beneficiary in each stay.  
To select the sample of GIP stays, we performed the following steps.  Using 
CMSs National Claims History file, we extracted all Medicare Part A 
hospice claims that had service dates in 2012 and were received through 
December 2012.  Each claim included information about the level of 
hospice care, such as GIP, and the setting, such as a SNF.  We combined the 
claims to identify all GIP stays.  We considered a GIP stay to be one or 
more claims for GIP for the same beneficiary in the same setting, from the 
same hospice, for which the claims represented consecutive periods.  We 
considered the periods to be consecutive if the first claims ending date was 
either the same day as or the day before the starting date of the subsequent 
claim, and so on. We identified 282,225 GIP stays in 2012 for 
252,759 beneficiaries.  
We selected a stratified simple random sample of 570 GIP stays from this 
file.  We did not contact the hospices that billed for five of the stays in our 
sample because these hospices were under investigation by OIG.  Our final 
sample included 565 stays.  
We used a contractor to collect the election statements and all certifications 
of terminal illness associated with each sampled stay.  We had response 
rates of 100 percent for election statements and 99 percent for certifications 
of terminal illness.  
Review of Election Statements and Certifications of Terminal 
Illness  
For each GIP stay, we used a standardized instrument based on Medicare 
coverage requirements and CMS guidance to review the beneficiarys 
election statement and certifications of terminal illness. 
Election Statements.  We reviewed the election statements to determine the 
extent to which they lacked required information or had other 
vulnerabilities.  Specifically, we determined whether the statement 
specified that the election was for the Medicare hospice benefit; included 
                                                                                                                           
42 For a detailed description of the sample see OIG, Hospice Inappropriately Billed 
Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491), March 2016. 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  17   
   
the information that the beneficiary waives certain Medicare services by 
electing hospice care; and included information about the palliative rather 
than curative nature of hospice care, as it related to the individuals 
terminal illness. We also reviewed information in the statements about 
revocation and discharge.  We further noted whether the hospice included 
any additional information in the election statements, such as the potential 
costs to beneficiaries, the length of Medicare hospice election periods, the 
levels of hospice care, and the services the hospice provides.   
Certifications of Terminal Illness.  We reviewed the certifications to 
determine the extent to which the physician met requirements that 
demonstrate involvement in the certification process.  Specifically, we 
determined whether a physician signed the document; whether it stated that 
the beneficiarys prognosis was for a life expectancy of 6 months or less if 
the terminal illness were to run its normal course, if it contained a narrative 
and, if so, whether the narrative reflected the beneficiarys clinical 
circumstances.  We also determined whether the certifying physician 
attested to basing the narrative on a review of the beneficiarys medical 
record and/or an examination of the beneficiary.   
Analysis 
We analyzed the results of the reviews of election statements to estimate 
the percentage of GIP stays for which the election statement lacked the 
required information or had other vulnerabilities.  We estimated the 
percentage of GIP stays for which the election statement included 
additional information that was beyond what was required.  We also 
analyzed the results of the reviews of the certifications to estimate the 
percentage of GIP stays for which the physician did not meet requirements 
when certifying and appeared to have limited involvement in determining 
that the beneficiary was appropriate for hospice care. 
   
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  18   
   
 
APPENDIX C 
Statistical Estimates and Confidence Intervals 
 
Sample Sizes, Point Estimates, and Confidence Intervals 
95-Percent Confidence Interval 
Sample  Point 
Estimate Characteristic  Size  Estimate  Lower Limit  Upper Limit 
Election Statements 
Percentage of GIP stays for which the hospice election statement 
lacked required information or had other vulnerabilities 
563  34.9%  30.0%  40.2% 
Percentage of GIP stays for which the election statement did not 
specify that the hospice benefit that the beneficiary was electing was 
Medicare hospice 
563  19.4%  15.5%  23.9% 
Percentage of GIP stays for which the election statement did not 
mention that the beneficiary was waiving coverage of certain 
Medicare services by electing hospice care, or inaccurately stated 
what Medicare benefits were waived  563  11.6%  8.4%  15.8% 
Percentage of GIP stays for which the election statement did not state 
that hospice care is palliative rather than curative 
563  9.5%1  6.7%  13.2% 
Percentage of GIP stays for which the election statement included 
inaccurate or unclear information about how a beneficiary may revoke 
the election of hospice care or how the hospice may discharge a 
beneficiary  563  3.6%  2.1%  6.2% 
Percentage of GIP stays for which the election statement mentioned 
potential costs to the beneficiary 
563  67.4%  62.2%  72.2% 
Percentage of GIP stays for which the election statement mentioned 
the length of periods 
563  63.8%  58.4%  68.8% 
Percentage of GIP stays for which the election statement noted that 
the beneficiary can change hospice providers 
563  48.4%  43.0%  53.8% 
Percentage of GIP stays for which the election statement included 
information on the levels of hospice care available 
563  48.2%  42.8%  53.6% 
Percentage of GIP stays for which the election statement included 
information on specific services that the hospice provides 
563  42.0%  36.9%  47.4% 
continued on the next page 
 
   
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  19   
   
Sample Sizes, Point Estimates, and Confidence Intervals (Continued) 
95-Percent Confidence Interval 
Sample  Point 
Estimate Characteristic  Size  Estimate  Lower Limit  Upper Limit 
Election Statements 
Percentage of GIP stays for which the election statement noted that 
hospice services were available 24/7 
563  30.7%  26.0%  35.8% 
Certifications of Terminal Illness 
Percentage of GIP stays for which the physician did not meet 
requirements when certifying and appeared to have limited 
562  14.1%  10.6%  18.5% 
involvement in determining that the beneficiary was appropriate for 
hospice care 
Percentage of GIP stays for which the certifying physician did not 
562  10.5%2  7.5%  14.5% 
include a narrative at all or included only the beneficiary's diagnosis 
Percentage of GIP stays for which the certifying physician did not 
562  4.6%  2.7%  7.5% 
include an attestation 
1 The point estimate was 9.47 percent, which rounded to 9 percent as a whole number in the text. 
2 The point estimate was 10.49 percent, which rounded to 10 percent as a whole number in the text. 
Source:  OIG analysis of hospice election statements and certifications of terminal illness, 2015. 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  20   
   
APPENDIX D 
Agency Comments 
 
 
 
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ACKNOWLEDGMENTS 
This report was prepared under the direction of Jodi Nudelman, Regional 
Inspector General for Evaluation and Inspections in the New York regional 
office, and Nancy Harrison and Meridith Seife, Deputy Regional Inspectors 
General.   
Nancy Harrison and Jenell Clarke-Whyte served as team leaders for this 
study.  Other Office of Evaluation and Inspections staff from the New York 
regional office who conducted the study include Lauren A. Haynes, 
Jennifer Karr, and Casey Lyons. Central office staff who provided support 
include Evan Godfrey, Kevin Farber, Christine Moritz, and 
Berivan Demir Neubert.  
 
Hospices Should Improve Their Election Statements and Certifications of Terminal Illness (OEI-02-10-00492)  24   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, 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 individuals 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 individuals.  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.