Long-Stay Hospice Patient Audits: Preparing for Targeted Review of Extended Lengths of Stay

Medicare does not limit how long a patient may receive hospice care. As long as the patient continues to be certified as terminally ill, with a life expectancy of six months or less if the illness runs its normal course, hospice benefits may continue through an unlimited number of 60-day benefit periods. Some patients legitimately live much longer than six months, because prognosis is inherently uncertain and hospice care can improve comfort and stability.

But long lengths of stay are one of the clearest signals reviewers use to target hospices. When a large share of a hospice's patients stay on service for many months or years, reviewers ask whether those patients were terminally ill when admitted and whether each recertification was supported. CMS's FY 2027 hospice final rule finalized a Service and Spending Variation Index (SSVI) that includes the percent of beneficiaries with lengths of stay of 180 days or more. CMS stated in that rule that long lengths of stay combined with high live discharge rates may signal inappropriate enrollment of ineligible beneficiaries.

This article explains why long stays attract review, the rules that apply, how to document continued eligibility for long-stay patients, how the aggregate cap fits in, and how to audit long-stay cases before reviewers do. It is educational and does not replace legal or professional advice.

Why Long Stays Attract Review

Data Targeting

Medicare contractors and CMS use claims data to identify hospices with unusual patterns. Measures related to long stays include:

• The percent of patients with stays over 180 days.

• Average and median lengths of stay.

• The number of patients in third and later benefit periods.

• Live discharges after long stays.

PEPPER for hospices has included long length of stay as a target area, and MACs have used length of stay as a Targeted Probe and Educate topic. The SSVI now adds a public, provider-level view.

Diagnoses With Uncertain Trajectories

Patients with dementia, chronic heart and lung disease, and other conditions with slow or uneven decline are more likely to have long stays. Reviewers look closely at whether documentation shows that these patients continue to meet eligibility criteria.

Settings

Patients in assisted living facilities and nursing facilities have historically had longer average stays, and OIG has examined hospice care in these settings. Reviewers may focus on facility-based patients with long stays.

Enforcement Context

In 2026, CMS imposed a nationwide moratorium on new hospice enrollments, suspended payments to hundreds of Los Angeles County hospices, and conducted nationwide hospice site visits. Long stays, high live discharge rates, and enrollment of patients who are not terminally ill are central concerns in these efforts.

The Rules That Apply

Eligibility

Under 42 CFR 418.20 and 418.22, a patient must be certified as terminally ill for each benefit period. Under 42 CFR 418.3, terminally ill means a medical prognosis of six months or less if the illness runs its normal course.

Benefit Periods

Under 42 CFR 418.21, benefit periods are two 90-day periods followed by unlimited 60-day periods. A patient who has been on hospice more than 180 days is in at least the third benefit period.

Face-to-Face Encounters

Under 42 CFR 418.22(a)(4), a hospice physician or hospice nurse practitioner must have a face-to-face encounter within 30 days before the third benefit period recertification and every recertification after that. For long-stay patients, this means a face-to-face encounter every 60 days. Through December 31, 2027, the encounter may be conducted via telehealth for the sole purpose of recertification, unless a statutory limit applies, and telehealth encounters on or after January 1, 2027 must be reported on the claim.

Narrative

Each recertification must include a physician narrative explaining the clinical findings that support a six-month prognosis. For third and later periods, the narrative must explain why the face-to-face findings support that prognosis.

Principal Diagnosis Restrictions

CMS does not permit certain codes, such as debility and adult failure to thrive, to be used as the principal hospice diagnosis. Hospices must code the condition that is the basis for terminal prognosis, along with related conditions, following ICD-10-CM guidelines.

The Aggregate Cap

Under 42 CFR 418.309, Medicare limits total hospice payments to a provider each cap year using an aggregate cap amount per beneficiary. The FY 2027 hospice final rule set the cap amount for the 2027 cap year at $36,174.75. Hospices with many long-stay patients are more likely to exceed the cap, which results in an overpayment that must be repaid.

Long stays and cap exceedances are related but separate issues. A hospice can exceed the cap even with eligible patients, and a hospice can be under the cap while still having patients who were not eligible. Reviewers may look at both.

What Reviewers Look For in Long-Stay Cases

Initial Eligibility

• Was the patient terminally ill at admission?

• Did admission documentation show disease severity and decline consistent with a six-month prognosis?

• Was the referral source appropriate, and did the patient or family understand hospice?

Continued Eligibility at Each Recertification

• Does each narrative explain why the patient continues to have a six-month prognosis?

• Do measurable indicators show progression, or does the record show stability or improvement?

• Did face-to-face encounters occur on time with complete attestations?

• Are narratives individualized, or copied from period to period?

Consistency Across the Record

• Do nursing notes, aide notes, and interdisciplinary group notes support the narrative?

• Do weights, intake, function, and symptoms match the described decline?

• Are hospitalizations, infections, and complications documented?

Plan of Care and Services

• Is the plan of care updated to reflect the patient's needs?

• Are visit frequencies consistent with the patient's condition?

• Are skilled visits provided as the patient nears death?

Documenting Continued Eligibility for Long-Stay Patients

Use Measurable Indicators Consistently

Record the same indicators at regular intervals so decline can be shown over time:

• Weight and body mass index, and mid-arm circumference where weight is hard to obtain.

• Percentage of meals consumed and fluid intake.

• Palliative Performance Scale or Karnofsky Performance Status.

• Functional Assessment Staging for dementia.

• Activities of daily living dependence.

• Oxygen saturation and oxygen use.

• Frequency of infections, wounds, falls, and hospitalizations.

• Symptom burden, such as pain, dyspnea, and agitation.

Compare Each Period With the Last

At each recertification, document what has changed since the previous period. A narrative that explains decline compared with specific prior values is more persuasive than one that simply states the patient is declining.

Explain Stability When It Occurs

Some patients stabilize for a time. If the patient has been stable, the narrative should explain why the prognosis remains six months or less, such as:

• The severity of the underlying disease.

• Comorbidities that increase risk of death.

• Recent complications or hospitalizations.

• The effect of hospice care in slowing decline, while the disease continues to progress.

If the patient no longer meets eligibility, the hospice should discharge the patient as no longer terminally ill, following discharge requirements.

Use Disease-Specific Clinical Indicators

MAC local coverage determinations and guidance describe clinical indicators that may support terminal prognosis for specific conditions. Documenting relevant indicators helps reviewers understand the prognosis, though the regulation requires the physician's clinical judgment and the guidelines are not strict requirements.

Document Related Conditions

Many long-stay patients have multiple conditions. Documenting how comorbidities and related conditions contribute to the prognosis strengthens the case.

Dementia and Long Stays

Dementia is one of the most common diagnoses among long-stay hospice patients. To document dementia prognosis:

• Record Functional Assessment Staging and changes over time.

• Document inability to ambulate, dress, or bathe without assistance, incontinence, and limited speech.

• Document complications such as aspiration pneumonia, urinary tract infections, sepsis, pressure injuries, recurrent fever, and weight loss.

• Document intake and nutritional decline.

• Document comorbidities.

• Avoid relying on the diagnosis alone without evidence of advanced stage and decline.

Heart and Lung Disease

For cardiopulmonary conditions:

• Document symptoms at rest, functional class, oxygen requirements, and response to treatment.

• Document recurrent hospitalizations and emergency visits.

• Document weight changes, edema, and declining function.

• Document comorbidities and complications.

Auditing Long-Stay Patients

Step 1: Identify Long-Stay Patients

Run a report of current and recently discharged patients with stays of more than 180 days, and those in the third or later benefit period.

Step 2: Prioritize

Prioritize patients with very long stays, stable or improving indicators, facility-based patients, diagnoses with uncertain trajectories, and patients referred by sources with unusual patterns.

Step 3: Review the Full Course

For each selected patient, review:

• Admission eligibility documentation.

• Every certification and recertification, including narratives and attestations.

• Every face-to-face encounter and attestation.

• Measurable indicators over time.

• Interdisciplinary group notes and plan of care updates.

• Hospitalizations and complications.

Step 4: Decide Whether Eligibility Is Supported

For each benefit period, decide whether the documentation supports a six-month prognosis. Use clinicians experienced in hospice eligibility.

Step 5: Act on Findings

• If a patient no longer meets eligibility, plan a compliant discharge.

• If earlier periods were not supported, evaluate overpayment obligations under 42 CFR 401.305, with counsel's guidance.

• Provide education to physicians and staff.

• Strengthen admission review and recertification processes.

Step 6: Monitor

Track the long-stay share, SSVI measures, live discharge rates, and audit results over time.

Strengthening Admission Review

Many long-stay problems begin at admission. Hospices should:

• Require physician review of eligibility documentation before admission.

• Use clinical indicators to support prognosis at admission.

• Evaluate referrals carefully, especially from sources with unusual patterns.

• Make sure patients and families understand hospice and the election.

• Avoid marketing practices that encourage enrollment of patients who are not terminally ill.

Interdisciplinary Group Review of Long-Stay Patients

• Review long-stay patients at every interdisciplinary group meeting, with specific discussion of eligibility.

• Document the discussion and the physician's assessment.

• Escalate questionable cases to the medical director.

• Consider a formal long-stay review committee.

Responding to a Length of Stay Review

When a MAC, UPIC, or other contractor requests records for long-stay patients:

• Log the request and calendar the deadline.

• Submit the complete record, including all benefit periods requested, certifications, narratives, face-to-face documentation, and clinical notes.

• Consider including a summary of measurable indicators over time to help the reviewer follow the patient's course, as long as it is accurate and supported by the record.

• Track decisions and appeal incorrect denials.

• Involve counsel for UPIC requests or any indication of an investigation.

Long-Stay Patients in Facilities

Patients living in assisted living facilities and nursing facilities present special documentation challenges.

• Coordinate with facility staff to obtain consistent weights, intake records, and functional assessments.

• Clarify the roles of hospice and facility staff in the plan of care.

• Document hospice visits and services distinctly from facility care.

• Watch for referral patterns from facilities that may suggest enrollment of patients who are not terminally ill.

• Review facility-based long-stay patients regularly.

Using SSVI and PEPPER Data

• Review your hospice's published SSVI scores and understand each measure.

• Compare your long-stay share with peers.

• Review PEPPER target areas related to length of stay and live discharges.

• Use the data to choose audit samples.

• Document legitimate explanations for outlier patterns, such as serving a population with specific diagnoses, while confirming eligibility in the records.

Common Mistakes

• Recertifying patients with stable or improving indicators without explanation.

• Copying narratives from period to period.

• Inconsistent measurement of indicators.

• Relying on diagnosis alone.

• Missing or late face-to-face encounters.

• Ignoring facility-based long-stay patients.

• Failing to review earlier periods when a long-stay patient is discharged as no longer terminally ill.

• Not monitoring SSVI, PEPPER, and cap data.

A Hypothetical Example

A hospice reviews its SSVI results and finds that the share of its patients with stays of 180 days or more is much higher than peers. It identifies 40 current long-stay patients, most with dementia and many in assisted living facilities. An audit of 15 cases finds that several had weights and FAST scores that were stable for more than a year, with narratives that repeated the same language at each recertification.

The hospice convenes its interdisciplinary group to review each case. Some patients show clear decline and remain eligible, with narratives updated to cite measurable changes. Others no longer meet eligibility and are discharged with appropriate notices and referrals. With counsel's guidance, the hospice evaluates whether earlier periods for those patients were supported and addresses overpayment obligations. It also strengthens its admission review and implements quarterly long-stay audits.

Physician Engagement for Long-Stay Patients

Physicians make the final eligibility decision, so their engagement is essential.

• Provide physicians with a summary of measurable indicators and changes before each recertification.

• Encourage physicians to examine long-stay patients or review face-to-face findings carefully.

• Train physicians on narrative requirements and the risks of copied language.

• Support physicians who decide a patient no longer qualifies.

• Review physician recertification patterns, such as physicians who never discharge patients.

A Long-Stay Patient Review Checklist

• Admission documentation supports terminal prognosis at the time of election.

• Every recertification is timely and signed by an authorized physician.

• Every narrative is individualized and cites measurable findings.

• Every face-to-face encounter is timely, performed by an eligible practitioner, and attested.

• Indicators are measured consistently and show progression or explain stability.

• Interdisciplinary group notes discuss eligibility.

• Complications and hospitalizations are documented.

• The plan of care reflects current needs.

• Coding reflects the terminal diagnosis and related conditions.

Cap Management Without Compromising Eligibility

• Monitor cap position throughout the cap year.

• Focus on admitting eligible patients at the right time rather than discharging eligible patients.

• Discharge patients who no longer qualify, regardless of cap position.

• Do not use revocations or discharges to manage the cap.

• Plan for repayment if the cap is exceeded.

Questions to Ask About Every Long-Stay Patient

• If a reviewer read only this benefit period's record, would the six-month prognosis be clear?

• What measurable changes have occurred since the last recertification?

• If the patient has been stable, does the narrative explain why the prognosis remains six months or less?

• Has the interdisciplinary group discussed eligibility recently, and is that discussion documented?

• Would we be comfortable defending each prior benefit period if asked?

Building a Long-Stay Review Committee

A formal committee can bring consistency to long-stay decisions.

• Include the medical director, a clinical manager, and a compliance representative.

• Review every patient reaching the third benefit period and periodically after.

• Use a standard review form covering indicators, narratives, face-to-face findings, and the plan of care.

• Record recommendations and follow up on them.

• Report trends to the compliance committee and governing body.

Coding Considerations for Long-Stay Patients

• Code the condition that is the basis of the terminal prognosis as the principal diagnosis.

• Include related conditions and comorbidities that contribute to the prognosis.

• Do not use codes CMS does not permit as principal hospice diagnoses, such as debility or adult failure to thrive.

• Update coding when the patient's condition changes.

Key Takeaways

• There is no limit on hospice length of stay, but long stays draw targeted review.

• The SSVI makes the share of patients with stays of 180 days or more publicly visible.

• Each recertification must stand on its own with measurable, individualized support.

• Admission review prevents many long-stay problems.

• Regular long-stay audits help hospices find and fix problems first.

Frequently Asked Questions

Is there a limit on how long a patient can receive hospice?

No. Patients may receive hospice as long as they continue to be certified as terminally ill.

Why do long stays attract audits?

Long stays may indicate that patients were not terminally ill when admitted or that recertifications were not supported. CMS's SSVI includes the percent of beneficiaries with stays of 180 days or more.

How often is a face-to-face encounter required for long-stay patients?

Before the third benefit period and every 60-day benefit period after that, within 30 days before each recertification.

What is the aggregate cap for 2027?

The FY 2027 final rule set the cap amount for the 2027 cap year at $36,174.75.

What if a long-stay patient is stable?

The narrative should explain why the patient still has a six-month prognosis. If the patient no longer meets eligibility, the hospice should discharge the patient.

Conclusion

Long hospice stays can be clinically appropriate, but they are one of the most visible indicators reviewers use to target hospices, and CMS's new SSVI makes them more visible still. Hospices that admit carefully, measure indicators consistently, write individualized narratives that compare each period with the last, complete face-to-face encounters on time, review long-stay patients regularly, discharge patients who no longer qualify, and audit their long-stay population will be well prepared for targeted review.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps hospices prepare for length of stay reviews through long-stay patient audits, SSVI and PEPPER analysis, recertification and narrative reviews, admission eligibility processes, and response support for contractor requests. If your hospice serves long-stay patients, please get in touch with us. We will be happy to help you with this topic.

References

• Electronic Code of Federal Regulations. 42 CFR Part 418, Subpart B, Eligibility, Election, and Duration of Benefits (including 418.20, 418.21, 418.22). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B

• Electronic Code of Federal Regulations. 42 CFR 418.3, Definitions. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-A/section-418.3

• Electronic Code of Federal Regulations. 42 CFR 418.309, Hospice Aggregate Cap. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-G/section-418.309

• Electronic Code of Federal Regulations. 42 CFR 418.26, Discharge From Hospice Care. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B/section-418.26

• 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

• Centers for Medicare & Medicaid Services. Hospice News and Announcements. https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/information-centers/hospices/news-announcements

• Centers for Medicare & Medicaid Services. CMS Announces Aggressive Nationwide Crackdown on Fraud with Six-Month Hospice and Home Health Agency Enrollment Moratoria (May 13, 2026). https://www.cms.gov/newsroom/press-releases/cms-announces-aggressive-nationwide-crackdown-fraud-six-month-hospice-home-health-agency-enrollment

• Centers for Medicare & Medicaid Services. Targeted Probe and Educate (TPE). https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/targeted-probe-educate-tpe

• U.S. Department of Health and Human Services, Office of Inspector General. Reports and Publications. https://oig.hhs.gov/reports/all/

• Centers for Disease Control and Prevention, National Center for Health Statistics. ICD-10-CM. https://www.cdc.gov/nchs/icd/icd-10-cm/index.html