Every hospice eligibility decision is, at its core, a physician's decision. Medicare requires a physician to certify that a patient is terminally ill, to review clinical information before admission and recertification, and to direct the medical component of the hospice's care. The hospice medical director sits at the center of these responsibilities.

When reviewers audit a hospice, they look not only at the certification form, but at whether a physician actually exercised clinical judgment. Narratives that read like templates, recertifications signed in batches, interdisciplinary group notes without physician input, and medical directors who appear to have little involvement in patient care can all suggest that eligibility decisions were not truly made by physicians. In enforcement cases, medical director arrangements have also been used to disguise payments for referrals.

In 2026, hospice scrutiny has reached new levels, with a nationwide enrollment moratorium, large-scale payment suspensions, and CMS's new Service and Spending Variation Index. This article explains the medical director's regulatory role, how to document physician involvement in eligibility decisions, compensation and referral risks, and how to audit medical director oversight. It is educational and does not replace legal or professional advice.

The Medical Director's Regulatory Role

Designation

Under the hospice Condition of Participation at 42 CFR 418.102, the hospice must designate a physician to serve as medical director. The medical director must be a doctor of medicine or osteopathy who is an employee of the hospice or under arrangement with the hospice. When the medical director is not available, a physician designated by the hospice assumes the same responsibilities and obligations.

Responsibility for the Medical Component of Care

The medical director, or physician designee, is responsible for the medical component of the hospice's patient care program. This includes coordinating with other physicians and health care professionals involved in each patient's care.

Initial Certification Review

Under 42 CFR 418.102, the medical director or physician designee reviews the clinical information for each hospice patient and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. In reaching this decision, the physician must consider at least:

• The primary terminal condition.

• Related diagnoses, if any.

• Current subjective and objective medical findings.

• Current medication and treatment orders.

• Information about the medical management of any of the patient's conditions unrelated to the terminal illness.

Recertification Review

Before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information.

Admission

Under 42 CFR 418.25, the hospice admits a patient only on the recommendation of the medical director, physician designee, or physician member of the interdisciplinary group, in consultation with or with input from the patient's attending physician, if any. In reaching the decision to certify, the physician must consider the principal diagnosis, other health conditions, and current clinically relevant information supporting all diagnoses.

Certification Sources

Under 42 CFR 418.22(c), the initial certification must be signed by the medical director, physician designee, or a physician member of the interdisciplinary group, and by the attending physician if there is one. Recertifications may be signed by the medical director, physician designee, or a physician member of the interdisciplinary group.

Discharge

Under 42 CFR 418.26, as revised by conforming changes in the FY 2027 hospice final rule, a written discharge order must be obtained from the hospice medical director, physician designee, or a physician member of the interdisciplinary group before a patient is discharged, with consultation of the attending physician when involved.

The Interdisciplinary Group

Under 42 CFR 418.56, the hospice must designate an interdisciplinary group that includes at least a doctor of medicine or osteopathy, a registered nurse, a social worker, and a pastoral or other counselor. The interdisciplinary group, in consultation with the patient's attending physician, prepares a written plan of care and reviews, revises, and documents the plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days.

The physician member of the interdisciplinary group should participate meaningfully in plan of care reviews. Reviewers may look at interdisciplinary group notes to see whether the physician discussed eligibility, symptom management, and changes in the patient's condition.

What Reviewers Look For

Evidence of Real Clinical Review

• Narratives that reflect the patient's specific clinical circumstances.

• Physician notes showing review of the record or examination.

• Interdisciplinary group notes documenting physician input.

• Physician orders that respond to changes in the patient's condition.

Red Flags

• Identical or near-identical narratives across patients or benefit periods.

• Large numbers of certifications signed on the same day.

• Physicians who certify very high numbers of patients relative to their time with the hospice.

• Physicians who never discharge patients or never question eligibility.

• Interdisciplinary group notes that list the physician as present but contain no physician input.

• Medical directors who serve many hospices.

• Certifications signed by physicians who are not enrolled in Medicare or validly opted out.

Medical Director Arrangements and Referrals

Enforcement actions have involved medical director agreements used to pay physicians for referrals. In January 2026, the Department of Justice announced a $34 million settlement with a home health company involving medical director arrangements with referring physicians, and OIG has announced hospice settlements involving kickback arrangements with medical directors. Reviewers and investigators may look at whether medical directors are also major referral sources and whether compensation reflects real work.

Documenting the Physician's Role

At Admission

• Document that the medical director, physician designee, or physician member of the interdisciplinary group reviewed the clinical information before admission.

• Document the physician's consideration of the terminal diagnosis, related conditions, other conditions, current findings, and medications.

• Document consultation with or input from the attending physician.

• Record the physician's recommendation to admit.

At Certification and Recertification

• Provide the physician with a clinical summary, including measurable indicators and changes since the last period.

• Have the physician compose the narrative personally.

• Place the narrative immediately before the signature or in a signed addendum, with the required attestation.

• Document the physician's review of face-to-face findings for third and later periods.

• Have the physician sign and date within the allowed windows.

In Interdisciplinary Group Meetings

• Record the physician's attendance and specific contributions.

• Document eligibility discussions, especially for long-stay patients and patients showing stability.

• Record decisions about level of care, symptom management, and discharge.

In Ongoing Care

• Document physician orders, including responses to symptom changes.

• Document physician visits, when made.

• Document consultations with attending physicians and other providers.

For Discharges

• Document the physician's review and discharge order.

• Document consultation with the attending physician.

Physician Designees and Coverage

• Designate physician designees in writing.

• Make sure designees understand certification and recertification requirements.

• Document when a designee acts in place of the medical director.

• Confirm that designees are enrolled in Medicare or validly opted out.

Physician Workload

Reviewers may question whether a physician could meaningfully review all the patients he or she certified. Hospices should:

• Track the number of certifications and recertifications each physician signs.

• Make sure physicians have enough time to review records.

• Avoid workflows that encourage batch signing without review.

• Use additional physicians or designees when census grows.

Medical Director Compensation and Compliance

Medical director arrangements must comply with the Anti-Kickback Statute and, when the physician refers patients, the physician self-referral law. Best practices include:

• A written agreement signed before services begin, with a defined term and duties.

• Compensation set in advance, consistent with fair market value, and not tied to the volume or value of referrals.

• Time logs or activity reports documenting services provided.

• A legitimate need for the number of medical directors.

• Periodic review of the arrangement by compliance and counsel.

• Screening against exclusion lists.

Medical directors should not be selected or paid based on their ability to refer patients.

Physician Enrollment

Physicians who certify hospice eligibility must be enrolled in Medicare or validly opted out. Telehealth face-to-face encounters may not be performed by practitioners who do not meet enrollment requirements. Hospices should verify enrollment status for the medical director, designees, interdisciplinary group physicians, and attending physicians.

Supporting Physicians With Clinical Summaries

Physicians make better eligibility decisions, and document them better, when they receive organized clinical information. Before each certification or recertification, hospices can prepare a summary that includes:

• The terminal diagnosis and related conditions.

• Measurable indicators at the start of the current period and at the last recertification, such as weight, intake, functional scales, and oxygen use.

• New complications, infections, falls, wounds, and hospitalizations.

• Symptom burden and medication changes.

• Face-to-face findings for third and later periods.

• Interdisciplinary group observations.

The summary helps the physician compose an individualized narrative. It should never contain pre-written narrative language for the physician to sign.

When Physicians Should Question Eligibility

A strong oversight program includes physicians who are willing to question eligibility. Physicians should:

• Ask for additional information when the record does not clearly support prognosis.

• Examine patients when needed.

• Recommend discharge when patients no longer meet eligibility criteria.

• Decline to certify patients who do not appear terminally ill at admission.

Hospices should support physicians who make these decisions, and should not pressure them to admit or recertify patients for business reasons.

The Medical Director's Broader Responsibilities

Beyond eligibility, the medical director typically:

• Oversees symptom management protocols.

• Participates in quality assessment and performance improvement.

• Reviews level of care decisions, such as general inpatient and continuous home care.

• Consults with attending physicians and other providers.

• Educates staff on clinical topics.

• Participates in compliance reviews of clinical documentation.

Documenting these activities, through meeting minutes, protocols, and education records, shows that the medical director is actively engaged.

Attending Physicians

Many patients have an attending physician who is not employed by the hospice. Hospices should:

• Obtain the attending physician's signature on the initial certification when designated.

• Communicate with the attending physician about changes in condition.

• Consult the attending physician before discharge, when involved.

• Verify the attending physician's enrollment status.

• Document attending physician changes with the patient's signed statement.

Interdisciplinary Group Documentation Tips

• Record who attended and in what role.

• For each patient reviewed, record the physician's assessment of eligibility and any recommended changes.

• Record discussion of long-stay patients specifically.

• Avoid notes that simply list "plan of care reviewed, no changes."

• Make sure decisions are reflected in updated plans of care.

Auditing Medical Director Oversight

Step 1: Inventory Physicians

List the medical director, designees, interdisciplinary group physicians, and their roles, agreements, and enrollment status.

Step 2: Review Certification Patterns

• Count certifications and recertifications per physician.

• Look for batch signing.

• Compare narrative language across patients.

Step 3: Review a Sample of Records

For a sample of patients, review:

• Admission documentation of physician review.

• Certifications and narratives.

• Interdisciplinary group notes for physician input.

• Physician orders and visits.

• Discharge orders.

Step 4: Review Arrangements

• Review medical director agreements, compensation, and time logs.

• Compare referral patterns with compensation arrangements.

Step 5: Correct and Educate

• Train physicians on certification, narrative, and documentation requirements.

• Adjust workflows to support real review.

• Restructure noncompliant arrangements with counsel's guidance.

• Evaluate overpayment obligations under 42 CFR 401.305 when audits find unsupported certifications.

A Medical Director Oversight Checklist

• Medical director designated in writing, with a current agreement.

• Physician designees designated in writing.

• All physicians enrolled in Medicare or validly opted out and screened against exclusion lists.

• Physician review documented before every admission.

• Narratives composed by physicians, individualized, and correctly placed and attested.

• Interdisciplinary group notes show physician participation.

• Recertification reviews documented before each period.

• Discharge orders signed by authorized physicians.

• Compensation consistent with fair market value and supported by time logs.

• Certification workload reasonable for each physician.

A Hypothetical Example

A hospice reviews its certifications and finds that one physician signed more than 200 recertifications in a single month, most with nearly identical narratives, and that interdisciplinary group notes listed the physician as present but recorded no physician comments. The physician also served as medical director for two other hospices.

The hospice adds physician designees, sets a reasonable workload per physician, provides clinical summaries before each recertification, removes narrative templates from its EHR, and requires interdisciplinary group notes to record physician input on eligibility for every patient reviewed. Counsel reviews the medical director agreement and compensation. A follow-up audit shows individualized narratives and documented physician participation.

Common Mistakes

• Allowing nurses or administrative staff to draft narratives for physician signature.

• Using EHR templates that pre-populate narrative text.

• Scheduling recertification signing in large batches without time for review.

• Recording physician attendance at interdisciplinary group meetings without physician input.

• Relying on a single physician for a large census.

• Failing to verify physician enrollment status.

• Selecting medical directors based on referral potential.

• Lacking time logs or documentation of medical director services.

Responding to Reviewer Questions About Physician Oversight

When reviewers or investigators ask about physician oversight, hospices should be prepared to provide:

• The medical director agreement and job description.

• Physician designee designations.

• Interdisciplinary group meeting minutes and attendance.

• Certification and recertification records.

• Physician time logs and activity reports.

• Evidence of physician education and quality activities.

• Enrollment verification records.

Questions Leadership Should Ask

• How many certifications does each physician sign per month, and is that reasonable?

• Do our narratives read as individualized?

• Do interdisciplinary group notes show real physician input?

• Have our physicians ever recommended discharge, and are they supported when they do?

• Are our medical director arrangements consistent with fair market value and documented?

Building an Oversight Calendar

A simple calendar helps the medical director and physicians stay on top of their responsibilities:

• Daily: review new referrals and admissions, and sign oral and written certifications.

• Weekly or more often: review upcoming recertifications and face-to-face encounters.

• Every 15 days or more often: participate in interdisciplinary group plan of care reviews.

• Monthly: review long-stay patients, live discharges, and level of care use.

• Quarterly: participate in quality and compliance reviews, and review certification audit results.

• Annually: review medical director agreements, physician designees, and enrollment status.

Physician Documentation of Face-to-Face Findings

For third and later benefit periods, the certifying physician must explain why the face-to-face findings support a six-month prognosis. When a nurse practitioner or another physician performs the encounter, the certifying physician should document review of those findings. The medical director should make sure that:

• Encounter notes reach the certifying physician promptly.

• Attestations state that findings were provided to the certifying physician when required.

• Narratives reference specific encounter findings.

• Encounters are in person when telehealth is not permitted, such as when the hospice is under enhanced oversight.

Physician Involvement in Level of Care Decisions

General inpatient care and continuous home care require physician involvement. The medical director or interdisciplinary group physician should document orders and assessments supporting these levels of care and review them regularly.

Questions to Ask on Every Certification

• Is there evidence that the physician reviewed this patient's record or examined the patient?

• Is the narrative clearly the physician's own work?

• Were the attending physician's views considered?

Staying Focused

Strong physician oversight protects patients first. When physicians are truly engaged, eligibility decisions are sound and documentation follows naturally.

Key Takeaways

• The medical director and physician designees are responsible for the medical component of hospice care.

• Physicians must review clinical information before admission and recertification.

• Narratives must be physician-composed and individualized.

• Interdisciplinary group notes should show physician participation.

• Physician workload, enrollment, and compensation all affect audit risk.

Frequently Asked Questions

Who can serve as hospice medical director?

A doctor of medicine or osteopathy who is a hospice employee or under arrangement with the hospice.

Does the medical director have to review every admission?

Admission requires the recommendation of the medical director, physician designee, or physician member of the interdisciplinary group, with attending physician input, and the medical director or designee reviews clinical information for certification.

How often must the plan of care be reviewed?

As often as the patient's condition requires, but at least every 15 calendar days.

Can the medical director also refer patients?

Arrangements with referring physicians must be carefully structured to comply with the Anti-Kickback Statute and physician self-referral law.

What suggests weak physician oversight?

Templated narratives, batch signing, high certification volumes, and interdisciplinary group notes without physician input.

Conclusion

Medicare relies on hospice physicians to make eligibility decisions, and reviewers look for evidence that physicians actually do. By documenting physician review at admission and recertification, ensuring narratives are individualized and physician-composed, recording physician participation in interdisciplinary group meetings, managing physician workload, verifying enrollment, and structuring medical director arrangements compliantly, hospices can show that their eligibility decisions rest on real clinical judgment.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps hospices strengthen medical director oversight through certification pattern audits, interdisciplinary group documentation reviews, physician education, workflow design, and support for counsel in reviewing medical director arrangements. If you want to document your physicians' role more effectively, please get in touch with us. We will be happy to help you with this topic.

References

• Electronic Code of Federal Regulations. 42 CFR 418.102, Condition of Participation: Medical Director. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-C/section-418.102

• Electronic Code of Federal Regulations. 42 CFR 418.56, Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-C/section-418.56

• Electronic Code of Federal Regulations. 42 CFR Part 418, Subpart B (including 418.22, 418.25, 418.26). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B

• Electronic Code of Federal Regulations. 42 CFR 401.305, Requirements for Reporting and Returning of Overpayments. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-A/part-401/subpart-D/section-401.305

• Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

• Federal Register. Medicare Program; FY 2027 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Program Requirements (August 3, 2026). https://www.federalregister.gov/documents/2026/08/03/2026-15686/medicare-program-fy-2027-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting

• U.S. Department of Health and Human Services, Office of Inspector General. Mahlega Abdsharafat and Creative Hospice Settle Health Care Kickback Claims for $9.2 Million. https://oig.hhs.gov/fraud/enforcement/mahlega-abdsharafat-and-creative-hospice-settle-health-care-kickback-claims-for-92-million

• U.S. Department of Justice. Traditions Health Agrees to Pay $34M to Resolve False Claims Act Liability Relating to Home Health Services Following Self Disclosure (January 22, 2026). https://www.justice.gov/opa/pr/traditions-health-agrees-pay-34m-resolve-false-claims-act-liability-relating-home-health

• U.S. Department of Health and Human Services, Office of Inspector General. General Compliance Program Guidance. https://oig.hhs.gov/compliance/general-compliance-program-guidance/

• U.S. Department of Health and Human Services, Office of Inspector General. Exclusions Program. https://oig.hhs.gov/exclusions/