Livanta CERT Hospice Eligibility Review

Hospice agencies operating under Medicare face increasing scrutiny regarding eligibility determinations and documentation. One of the most critical audit programs impacting hospice reimbursement is the Comprehensive Error Rate Testing (CERT) program. Within this program, Livanta LLC plays a significant role in reviewing hospice claims for eligibility compliance.

Hospice eligibility reviews under CERT focus heavily on whether patients meet Medicare’s criteria for terminal illness and whether documentation supports that determination. Failure to meet these standards can result in claim denials, recoupment, and further audit escalation.

This guide provides a comprehensive overview of Livanta CERT hospice eligibility reviews, including audit triggers, documentation requirements, common denial reasons, and best practices for compliance.

What Is the CERT Program?

The Comprehensive Error Rate Testing (CERT) program is a CMS initiative designed to measure improper payment rates in Medicare Fee-for-Service. The program is administered by the Centers for Medicare & Medicaid Services (CMS) and involves random sampling of claims to assess compliance.

Unlike Targeted Probe and Educate (TPE) reviews, CERT reviews are statistically driven and not targeted based on provider behavior. However, findings from CERT can influence future audit activity.

Role of Livanta in Hospice CERT Reviews

Livanta LLC is responsible for reviewing hospice claims selected under CERT. Livanta evaluates whether services billed to Medicare meet eligibility and coverage requirements.

Key Responsibilities of Livanta:

• Requesting documentation through Additional Documentation Requests (ADRs)

• Reviewing clinical records for eligibility compliance

• Determining whether claims meet Medicare requirements

• Reporting findings to CMS

Livanta’s determinations directly impact whether claims are upheld or denied.

Hospice Eligibility Requirements Under Medicare

To qualify for hospice under Medicare, patients must meet strict eligibility criteria.

Core Eligibility Requirements:

• Certification of terminal illness with a life expectancy of six months or less

• Election of hospice benefit

• Acceptance of palliative rather than curative care

Eligibility must be supported by clinical documentation and physician certification.

CERT Hospice Eligibility Review Process

Understanding the review process is critical for timely and compliant responses.

Step 1: ADR Notification

Livanta sends an Additional Documentation Request (ADR) identifying:

• Claims selected for review

• Required documentation

• Submission deadline

Failure to respond results in automatic claim denial.

Step 2: Documentation Submission

Hospice agencies must submit a complete documentation package, including:

• Certification of Terminal Illness (CTI)

• Physician narratives

• Plan of Care (POC)

• Interdisciplinary Group (IDG) documentation

• Nursing and clinical notes

• Face-to-face encounter documentation (if applicable)

Step 3: Medical Review

Livanta evaluates whether:

• The patient meets hospice eligibility criteria

• Documentation supports terminal prognosis

• Clinical records demonstrate decline

Step 4: Determination

After review, Livanta issues:

• Approval

• Partial denial

• Full denial

Findings contribute to national error rate calculations.

Key Documentation Requirements for Hospice Eligibility

Documentation must clearly support the patient’s terminal condition and prognosis.

1. Certification of Terminal Illness (CTI)

The CTI must include:

• Physician certification

• Clinical justification for terminal prognosis

• Timely completion and signatures

Incomplete or generic CTIs are a major denial driver.

2. Physician Narrative

The narrative must:

• Be patient-specific

• Describe clinical condition and decline

• Support a prognosis of six months or less

Generic or templated narratives are frequently denied.

3. Clinical Documentation of Decline

Records must demonstrate:

• Disease progression

• Functional decline

• Worsening symptoms

This is critical for ongoing eligibility.

4. Interdisciplinary Group (IDG) Documentation

Hospice care requires team-based planning.

Documentation must show:

• IDG involvement in care planning

• Regular updates to the Plan of Care

• Coordination among disciplines

5. Face-to-Face Encounter Documentation

For recertification periods, documentation must include:

• Face-to-face visit by a qualified practitioner

• Clinical findings supporting continued eligibility

Common Reasons for CERT Hospice Denials

Livanta frequently identifies recurring deficiencies in hospice documentation.

1. Insufficient Evidence of Terminal Illness

• Documentation does not support a six-month prognosis

• Lack of clinical indicators

2. Weak or Generic Physician Narratives

• Copy-paste language

• Lack of individualized patient information

3. Lack of Documented Clinical Decline

• No evidence of disease progression

• Stable condition without justification for hospice

4. Incomplete or Missing CTI

• Missing signatures

• Late certification

5. Inconsistent Documentation

• Conflicting information across records

• Mismatch between physician and nursing notes

Impact of CERT Reviews on Hospice Agencies

CERT reviews can significantly affect financial and operational performance.

Potential Impacts Include:

• Claim denials and recoupment

• Increased scrutiny from CMS

• Higher likelihood of targeted audits

• Administrative burden

Agencies must treat CERT reviews as high-risk compliance events.

Best Practices to Prevent CERT Denials

Proactive compliance strategies are essential.

1. Strengthen Physician Narratives

Ensure narratives are:

• Detailed and patient-specific

• Clearly linked to prognosis

2. Document Clinical Decline Thoroughly

Include:

• Objective data (weight loss, lab values)

• Functional decline (ADLs, PPS scores)

3. Conduct Internal Chart Audits

Regularly review:

• Eligibility documentation

• CTIs and narratives

• IDG documentation

4. Train Staff on Hospice Eligibility

Staff must understand:

• Medicare eligibility criteria

• Documentation requirements

5. Standardize Documentation Practices

Use structured templates while ensuring individualized content.

How to Respond Successfully to a Livanta ADR

A strong response is critical.

Key Steps:

• Assign a dedicated audit response team

• Review each claim thoroughly

• Submit complete and organized documentation

• Address potential deficiencies proactively

• Meet submission deadlines

What Happens After a Denial?

If a claim is denied, agencies may:

• File an appeal (redetermination)

• Submit additional documentation

• Address deficiencies in future claims

Repeated denials increase audit risk.

Escalation Risks

Agencies with persistent issues may face:

• Targeted Probe and Educate (TPE) reviews

• Referral to Unified Program Integrity Contractors (UPIC)

• Recovery Audit Contractor (RAC) audits

• Extrapolated overpayment demands

Alignment with Medicare Hospice Conditions of Participation

CERT reviews align closely with hospice Conditions of Participation, including:

• Patient eligibility determination

• Interdisciplinary care planning

• Documentation accuracy

• Quality of care

Agencies aligned with CoPs are more likely to pass audits.

Conclusion

Livanta CERT hospice eligibility reviews represent a critical compliance challenge for hospice agencies. With increasing focus on eligibility and documentation, agencies must maintain strong clinical and compliance systems.

Facilities that invest in documentation quality, staff training, and internal audits are better positioned to avoid denials and maintain compliance.

Work with HealthBridge for CERT and Hospice Compliance Support

HealthBridge provides expert consulting and compliance solutions for hospice agencies, including:

• CERT audit preparation and response

• Hospice eligibility documentation audits

• Physician narrative development support

• Plan of Correction (POC) creation

• Ongoing compliance monitoring

HealthBridge helps agencies navigate complex audits and maintain regulatory compliance.

References

• CMS Comprehensive Error Rate Testing (CERT) Program
  https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/cert

• Livanta Hospice Medical Review Information
  https://www.livanta.com

• Medicare Benefit Policy Manual (Hospice)
  https://www.cms.gov/regulations-and-guidance/guidance/manuals

• Hospice Conditions of Participation
  https://www.ecfr.gov

• Unified Program Integrity Contractors (UPIC) Overview
  https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/upic