Hospice Medicare Compliance Audit: Election Statement and Revocation Documentation Review

The hospice election statement is the document through which a beneficiary, or their representative, formally elects the Medicare hospice benefit, waiving standard Medicare coverage for treatment of the terminal illness and related conditions in favor of hospice’s palliative approach. Since CMS’s significant 2020 revisions requiring a detailed election statement addendum, and given the ongoing significance of proper revocation documentation whenever a patient chooses to discontinue hospice care, election and revocation documentation has become a distinct, closely reviewed compliance area separate from the certification and level-of-care documentation addressed elsewhere in hospice compliance.

This article explains the current election statement and addendum requirements, the documentation standards governing revocation, why this documentation draws sustained audit attention, and how hospices should structure an internal compliance review addressing election and revocation documentation comprehensively. It closes with how HealthBridge US supports hospices strengthening election statement and revocation compliance.

The Election Statement Requirement

Under 42 CFR § 418.24, a beneficiary or representative electing hospice care must file a signed election statement with the hospice, identifying the hospice that will provide care, the beneficiary’s or representative’s acknowledgment that they have been given a full understanding of hospice care, the effective date of election, and an acknowledgment that electing hospice care constitutes a waiver of standard Medicare coverage for the terminal illness and related conditions. The election statement must also identify the attending physician, if the beneficiary has designated one, and must include the beneficiary’s or representative’s acknowledgment that they understand the palliative, rather than curative, nature of hospice care.

CMS released updated model election statement language in 2024 specifically intended to help hospices meet these content requirements more clearly and consistently, and hospices should ensure their current election statement template reflects this updated model or, at minimum, includes every required content element the model addresses.

The Election Statement Addendum Requirement

Since October 2020, CMS has required hospices to provide, upon request, a separate election statement addendum specifically titled to reflect its purpose of notifying the beneficiary or representative, in writing, of the specific conditions, items, services, and drugs the hospice has determined are unrelated to the terminal illness and related conditions, and therefore will not be covered by the hospice. If the addendum is requested at the time of the initial election, the hospice must furnish it in writing within 5 days of the election’s effective date. If requested later, during the course of hospice care, the hospice must furnish it within 72 hours of the request.

Because the addendum’s content can change as a patient’s condition evolves, hospices must update it to reflect any changes and provide the updated version in writing to the beneficiary or representative. CMS released an updated model addendum in 2024 alongside the updated model election statement, and hospices should ensure their internal addendum template and process reflect current CMS guidance rather than an earlier version of the requirement that may not fully capture subsequent clarifications.

Documentation Standards for Revocation

A hospice patient or representative may revoke the election of hospice care at any time, during any benefit period, returning the patient to standard Medicare coverage for the remainder of that benefit period. CMS requires that a revocation be documented through a signed statement indicating the patient’s or representative’s intent to revoke hospice care, including the effective date, which cannot be earlier than the date the revocation statement is completed.

Revocation documentation should be maintained just as carefully as election documentation, since a hospice that continues billing for a patient after a revocation’s effective date, or that lacks clear documentation of the revocation’s timing, creates a distinct compliance exposure independent of any question about the appropriateness of the care furnished before the revocation occurred.

Why Election and Revocation Documentation Draws Sustained Audit Attention

Because the election statement and addendum establish the beneficiary’s informed, voluntary election of hospice care and their understanding of what will and will not be covered, gaps in this documentation raise a distinct compliance concern from the clinical eligibility questions addressed by certification and level-of-care review — namely, whether the beneficiary’s election was genuinely informed and properly documented in the first place. MACs and other reviewing contractors specifically verify that required election statement content elements are present, that the addendum was furnished within the applicable timeframe when requested, and that any revocation was properly documented with a clear, unambiguous effective date.

Building a Comprehensive Election and Revocation Documentation Review

An effective internal review verifies that the hospice’s current election statement template includes every element CMS requires, ideally aligned with the 2024 model language, and that intake staff consistently obtain a properly signed and dated election statement before billing any hospice services. The review should separately verify the hospice’s addendum process — confirming that requests for the addendum are tracked, that the 5-day or 72-hour timeframe is consistently met depending on when the request was made, and that any addendum content changes during a patient’s stay are properly updated and redistributed in writing.

For revocations, the review should confirm that a signed revocation statement exists for every discontinued hospice election, with a clear effective date, and that hospice billing ceased appropriately as of that effective date without continuing to bill for services after the patient returned to standard Medicare coverage.

Building an Effective Response to an Election or Revocation Documentation Challenge

When a MAC or other reviewing contractor challenges election or revocation documentation, the response should include the complete signed election statement, evidence of addendum compliance if the addendum was requested, and, where relevant, the signed revocation statement with its documented effective date. Where a genuine gap exists — an election statement missing a required content element, or an addendum furnished outside the required timeframe — the hospice should acknowledge the gap candidly while providing whatever additional documentation exists to demonstrate the beneficiary’s election was nonetheless genuinely informed and voluntary.

Common Election and Revocation Documentation Gaps

Several recurring gaps appear in election and revocation documentation reviews. Election statements missing specific required content elements, particularly the waiver-of-standard-coverage acknowledgment or attending physician identification, are among the most common findings. Addenda furnished outside the required 5-day or 72-hour window, or not updated when the underlying non-covered items and services determination changes during the patient’s stay, represent a distinct and frequently cited gap specific to the 2020 addendum requirement. Missing or ambiguous revocation documentation, including revocations lacking a clear effective date or continued billing past a documented revocation date, round out the most common findings in this area.

Coordinating Intake, Clinical, and Billing Staff Around Election Compliance

Because election statement, addendum, and revocation documentation touches intake, clinical, and billing functions at different points in a patient’s hospice stay, sustained compliance depends on clear ownership and coordination across all three. Intake staff obtaining the initial election statement should verify every required content element is present and properly signed and dated before the patient is admitted to hospice billing, rather than treating the election statement as a formality completed quickly amid the many other tasks involved in a hospice admission. Clinical staff should understand that any request for the addendum, whether made at election or later during the course of care, must be routed promptly to whoever is responsible for generating and delivering it within the applicable 5-day or 72-hour deadline, and should also understand their role in flagging when the addendum’s content needs updating as the patient’s condition and the hospice’s non-covered items and services determination evolves. Billing staff should confirm, before submitting any claim, that a complete, properly executed election statement is on file, and should have a clear, immediate process for identifying and halting billing as of a revocation’s documented effective date, rather than relying on eventual reconciliation to catch a billing period that should have ended earlier.

Building Proactive Election and Revocation Compliance Monitoring

Hospices benefit from a recurring internal audit specifically sampling recent elections, addendum requests, and revocations, verifying that content, timing, and signature requirements are being met consistently across different intake staff and admission circumstances. This kind of proactive monitoring is particularly valuable given how frequently CMS has updated election-related guidance in recent years, since a hospice’s internal templates and processes can drift out of alignment with current requirements if not periodically reviewed and refreshed against the latest CMS model language and subregulatory guidance.

The Relationship Between Election Compliance and Beneficiary Understanding

Beyond its role as a Medicare payment condition, the election statement and addendum requirement exists to ensure beneficiaries and their families genuinely understand what they are agreeing to when they elect hospice care — a substantial life decision that involves waiving standard Medicare coverage for the terminal illness in favor of a palliative approach. Hospices that treat election documentation purely as a billing formality, rather than as a genuine communication tool ensuring the beneficiary and family understand hospice’s scope and limitations, risk both compliance exposure and a less satisfactory experience for patients and families navigating an already difficult transition. Framing election and addendum discussions as a substantive conversation, supported by but not limited to the required written documentation, tends to produce both stronger compliance outcomes and a better overall experience for the beneficiary and family than treating the election paperwork as a signature to be obtained quickly and set aside, and staff trained to view this documentation as a meaningful communication tool rather than a purely administrative step tend to produce more complete, thoughtful records that also hold up better under subsequent audit review.

How HealthBridge US Supports Your Hospice

Election statement, addendum, and revocation documentation establish the foundational, beneficiary-facing basis for hospice election, and gaps here raise a distinct compliance concern from clinical eligibility questions addressed elsewhere in hospice review. HealthBridge US supports hospices with election statement and addendum compliance audits, revocation documentation review, intake process design aligned with current CMS model language, and audit response support when election or revocation documentation is challenged. If your hospice wants to strengthen election and revocation compliance or needs support responding to an active audit, HealthBridge US is here to help — contact our team to discuss your hospice compliance audit and documentation review needs.

Keeping Templates Current as CMS Guidance Evolves

Because CMS has revised election statement and addendum guidance multiple times since the addendum requirement first took effect, hospices should assign clear ownership for monitoring CMS updates in this specific area and for promptly incorporating any new model language or clarified content requirements into internal templates. A hospice relying on an outdated election statement or addendum template, even one that was fully compliant when first adopted, risks accumulating a systemic documentation gap across every subsequent election until the template is updated, making this an area where periodic, deliberate review is considerably more valuable than a one-time compliance effort.

References

• Electronic Code of Federal Regulations. 42 CFR § 418.24 (Election of Hospice Care). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B/section-418.24

• Centers for Medicare & Medicaid Services. “Model Example of Hospice Election Statement” (March 2024). https://www.cms.gov/files/document/model-example-hospice-election-statement-march-2024.pdf

• 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

• Centers for Medicare & Medicaid Services. MM12491, “Manual Updates and Clarification to Election Statement, Addendum, and Extension of the Hospice Cap.” https://www.cms.gov/files/document/mm12491-manual-updates-clarification-election-statement-addendum-and-extension-hospice-cap.pdf

• Centers for Medicare & Medicaid Services. “Additional Documentation Request.” https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-education/additional-documentation-request

• Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 29 (Appeals). https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c29.pdf

HealthBridge US is here to help. Our compliance specialists support Hospices with election statement, addendum, and revocation documentation review — contact us to protect your organization’s reimbursement.My post content