OIG Work Plan 2026 for Hospice: Active Audits of Levels of Care and Documentation

The HHS Office of Inspector General (OIG) Work Plan lists the audits and evaluations OIG has planned or underway. OIG updates it continuously, and hospice has been one of its most consistent areas of focus. In 2026, several hospice items remain active, and OIG continues to issue reports that find unsupported terminal prognosis and unsupported levels of care.

For example, in July 2026 OIG completed a Medicare hospice provider compliance audit of a Phoenix, Arizona hospice. Of 100 sampled claims, OIG found 15 that did not comply with Medicare requirements, most because the clinical record did not support a life expectancy of six months or less, and estimated that the hospice received at least $8.6 million in unallowable payments. In an earlier audit of a large Florida hospice's general inpatient and continuous home care claims, OIG found that 89 of 100 sampled claims did not comply with Medicare requirements.

This article explains how the OIG Work Plan works, the active hospice items, what recent OIG hospice audits have found, how OIG audits are conducted, and how hospices can prepare. It is educational and does not replace legal or professional advice.

How the OIG Work Plan Works

The Work Plan lists audits and evaluations by item. Each item includes a description, the responsible OIG component, and, when completed, links to the resulting reports. OIG's Office of Audit Services conducts audits, often of individual providers, while the Office of Evaluation and Inspections conducts broader evaluations and data briefs.

OIG audit reports include recommendations, such as refunding estimated overpayments, but OIG's recommendations are not final determinations. CMS and its contractors decide whether overpayments exist and recover them, subject to the provider's appeal rights.

Active Hospice Work Plan Items

The following hospice items appear on OIG's Work Plan. Hospices should check OIG's website for current status, because items are added, updated, and completed throughout the year.

Review of Hospices' Compliance With Medicare Requirements

This audit series reviews whether Medicare payments for hospice services complied with Medicare requirements under 42 CFR Part 418. Auditors review hospice medical records and billing documentation. According to OIG's Work Plan page, the series includes 24 projects, with 8 active and 16 completed. Completed reports in this series have identified estimated overpayments ranging from about $1.9 million to more than $140 million.

Audit of Selected, High-Risk Medicare Hospice General Inpatient Services

OIG describes general inpatient care as having the second-highest daily rate Medicare pays for hospice care. This audit focuses on high-risk general inpatient claims and will determine whether hospices that billed for general inpatient care complied with Medicare requirements.

Review of Hospice Inpatient and Aggregate Cap Calculations

This item reviews the calculation of the hospice inpatient cap, which limits inpatient days to 20 percent of a hospice's total Medicare patient care days, and the aggregate cap. Errors in these calculations can result in overpayments that are not recovered.

New Hospice Provider Enrollments

In 2025, OIG added an evaluation titled "Trends, Patterns, and Key Comparisons Related to New Medicare Hospice Provider Enrollments May Indicate the Need for Further Oversight," designed to evaluate trends and potential vulnerabilities related to new hospice enrollments. OIG indicated that a data brief was expected in 2026. This work aligns with CMS's 2026 nationwide hospice enrollment moratorium and enhanced oversight of new hospices.

Other Hospice-Related Work

OIG has also listed work related to state Medicaid hospice payments and other hospice topics. Hospices that serve Medicaid patients should review those items.

What Recent OIG Hospice Audits Have Found

Hospice of the Valley - West (July 2026)

OIG's July 2026 audit of Hospice of the Valley - West, a not-for-profit hospice in Phoenix, reviewed a random sample of 100 claims from a population of 20,780 claims paid from July 1, 2020 through June 30, 2022. OIG found:

• 15 of 100 sampled claims did not comply with Medicare requirements.

• 14 claims lacked sufficient clinical documentation to support a terminal prognosis of six months or less.

• 1 claim did not support the general inpatient level of care for some days, which should have been billed at the routine home care level.

• OIG estimated at least $8.6 million in unallowable payments, the lower limit of its confidence interval, with a point estimate of about $14.4 million.

OIG recommended that the hospice refund the estimated overpayment, consider auditing claims after the audit period for similar errors, and provide additional training on terminal prognosis and level-of-care requirements. The hospice did not concur with the recommendations.

Vitas Healthcare Corporation of Florida (July 2022)

OIG's audit of general inpatient and continuous home care claims found that 89 of 100 sampled claims did not comply with Medicare requirements. The clinical record did not support the continuous home care level of care for 68 claims, did not support the general inpatient level of care for 28 claims, and continuous home care services were not documented or supported for 23 claims, with some claims having more than one error. OIG's recommendations in this audit series included an estimated refund of more than $140 million.

Other Audits in the Series

OIG's Work Plan page lists completed hospice compliance audits from 2020 to 2022 with estimated overpayments including about $47.4 million for one Florida hospice, about $42.3 million for another, about $24.7 million for another hospice, and amounts from about $1.9 million to $13 million for others. Common findings across these audits have included:

• Clinical records that did not support terminal prognosis.

• Levels of care not supported, especially general inpatient and continuous home care.

• Missing or invalid certifications.

• Missing or invalid election statements.

• Missing face-to-face encounter documentation.

How OIG Hospice Audits Are Conducted

Selection

OIG typically selects hospices using data analysis, such as high levels of care, long lengths of stay, or other risk indicators.

Sampling

OIG usually selects a statistically valid random sample, often 100 claims, from the hospice's claims during a defined audit period. It may stratify the sample, for example by level of care.

Medical Review

OIG often uses independent medical review contractors to determine whether claims met Medicare requirements, including terminal prognosis and level of care.

Extrapolation

OIG estimates the total overpayment for the population using the sample results, typically recommending recovery of the lower limit of a 90 percent confidence interval.

Report and Recommendations

OIG issues a draft report, considers the hospice's written comments, and issues a final report with recommendations. Recommendations usually include refunding the estimated overpayment, using the 60-day rule to identify and return similar overpayments outside the audit period, and strengthening policies and training.

Recovery and Appeals

CMS and its contractors determine whether to recover overpayments. Hospices retain appeal rights through the Medicare appeals process, including the ability to challenge medical review findings and the statistical methodology.

Lessons From OIG Findings

Terminal Prognosis Is the Biggest Risk

Many OIG findings involve clinical records that do not support a six-month prognosis. Hospices should make sure each benefit period's record shows measurable decline or explains stability.

Levels of Care Are a Close Second

General inpatient and continuous home care claims are frequent targets. Every day must be supported.

Technical Requirements Still Matter

Certifications, election statements, and face-to-face encounters can lead to findings even when care was appropriate.

Findings Extend Beyond the Audit Period

OIG routinely recommends that hospices identify and return similar overpayments outside the audit period under the 60-day rule, which can greatly expand financial exposure.

Common OIG Findings in Detail

Terminal Prognosis Not Supported

OIG and its medical reviewers look for clinical documentation that supports a life expectancy of six months or less for each benefit period sampled. Findings often involve:

• Patients with stable weight, intake, and function over long periods.

• Records that describe chronic conditions without evidence of decline.

• Narratives that do not explain why the patient remained terminally ill.

• Lack of measurable indicators.

General Inpatient Care Not Supported

Findings often involve:

• Symptoms that could have been managed at a lower level of care.

• General inpatient days that continued after symptoms were controlled.

• Missing daily documentation.

Continuous Home Care Not Supported

Findings often involve:

• No documented crisis.

• Fewer than eight hours of care or nursing not more than half of hours.

• Missing time documentation.

Technical Errors

Findings may involve missing or invalid certifications, election statements, or face-to-face encounters.

The 60-Day Rule After an OIG Audit

OIG commonly recommends that hospices exercise reasonable diligence to identify, report, and return overpayments outside the audit period in accordance with the 60-day rule at 42 CFR 401.305. This means an OIG audit can lead to a broader internal review covering several years. Hospices should:

• Work with counsel to define the scope of the review.

• Use statistically valid methods if estimating overpayments.

• Document the investigation and its timing.

• Report and return overpayments through appropriate channels.

Statistical Issues in OIG Audits

OIG uses statistical sampling and extrapolation. Hospices that receive extrapolated findings should consider:

• Whether the sampling frame was defined correctly.

• Whether the sample was random and properly documented.

• Whether the calculations were correct.

• Whether claims overturned on appeal reduce the estimate.

A qualified statistician can help evaluate these issues, and challenges to the methodology may be raised during appeals.

Patterns OIG Uses to Select Hospices

OIG often selects hospices for audit based on risk indicators in claims data, such as:

• High shares of general inpatient or continuous home care.

• Long average lengths of stay.

• High shares of patients in nursing facilities or assisted living.

• High live discharge rates.

• Rapid growth.

Hospices can review their own data against these indicators.

How to Prepare for an OIG Audit

Monitor the Work Plan

Check OIG's Work Plan and recent reports regularly for hospice items.

Audit High-Risk Areas

• Terminal prognosis for long-stay patients.

• General inpatient and continuous home care days.

• Certifications, narratives, and face-to-face encounters.

• Election statements and addenda.

• Live discharges and revocations.

Use Statistically Valid Samples When Estimating Exposure

If internal audits suggest problems, consider counsel-directed reviews using statistically valid samples to estimate exposure and support 60-day rule compliance.

Train Staff

Provide training on terminal prognosis documentation and level-of-care requirements, which OIG frequently recommends.

Prepare a Response Process

• Identify a coordinator and counsel.

• Plan for producing records quickly.

• Plan for reviewing OIG's medical review findings and statistical methods.

• Plan for responding to the draft report.

Responding to an OIG Audit

Engagement Letter and Entrance Conference

OIG typically notifies the hospice by letter and holds an entrance conference. Involve counsel early, understand the scope, and designate a single point of contact.

Records Production

Provide complete, organized records for every sampled claim. Never alter documents.

Reviewing Findings

When OIG shares preliminary findings, review each claim carefully with qualified clinicians, and consider an independent review.

Commenting on the Draft Report

Submit written comments explaining disagreements, with supporting documentation. OIG includes the hospice's comments in the final report.

After the Final Report

When the MAC issues an overpayment demand, decide whether to appeal, and consider challenging both medical review findings and the statistical methodology. Evaluate obligations for claims outside the audit period.

Lessons From the Hospice of the Valley Audit

The July 2026 audit of a not-for-profit hospice shows that OIG findings are not limited to suspected fraud. A relatively low error rate of 15 out of 100 claims still produced an estimated overpayment of at least $8.6 million because the hospice's claim population was large. Lessons include:

• Even small error rates can create large extrapolated overpayments.

• Terminal prognosis documentation is the most common issue.

• OIG recommends training and look-back reviews, not just refunds.

• Hospices may disagree with findings, but must still manage the appeals and repayment process.

Questions Leadership Should Ask

• What share of our claims would a medical reviewer find lacking terminal prognosis support?

• How do our general inpatient and continuous home care use compare with peers?

• What would an extrapolated overpayment look like if 10 percent of our claims were found unsupported?

• Do we have a process to respond to an OIG engagement letter?

OIG Findings and Other Oversight

OIG findings often reinforce other oversight efforts. CMS's Service and Spending Variation Index highlights long stays, live discharges, levels of care, and non-hospice spending. MACs and Unified Program Integrity Contractors review similar issues. And OIG's work on new hospice enrollments aligns with CMS's moratorium and enhanced oversight of new hospices. A hospice that addresses OIG's common findings reduces risk across all of these programs.

A Hypothetical Example

A hospice with many long-stay patients and frequent general inpatient use reviews recent OIG reports and decides to conduct a counsel-directed audit. A statistically valid sample shows that about 12 percent of claims lack sufficient documentation of terminal prognosis, mostly for patients with dementia on service more than a year, and that several general inpatient stays continued after symptoms were controlled.

The hospice retrains physicians and nurses, implements long-stay reviews and daily general inpatient reviews, and, with counsel, evaluates and returns identified overpayments. When the hospice later receives an OIG engagement letter, it is prepared with organized records, documentation of its compliance efforts, and an understanding of its risk areas.

Common Myths

• "OIG only audits fraudulent hospices." OIG audits established and not-for-profit hospices too.

• "A low error rate means low exposure." Extrapolation can turn a modest error rate into a large overpayment.

• "OIG's findings are final." CMS contractors make overpayment determinations, and hospices can appeal.

Watching for New OIG Items

OIG adds Work Plan items throughout the year and often publishes related data briefs. Hospices should review new items monthly and consider whether their operations match the risks OIG describes.

Using OIG Reports as Training Tools

OIG reports describe specific documentation problems in plain terms. Hospices can use them in training by:

• Summarizing the findings for clinical staff.

• Comparing the findings with the hospice's own records.

• Discussing how to document differently.

• Tracking whether internal audits show improvement.

Responding to an Engagement Letter

When an OIG engagement letter arrives, the first week matters:

• Notify leadership and counsel.

• Identify a single point of contact.

• Review the scope and audit period.

• Begin assembling records for the sample when it is provided.

• Prepare for the entrance conference.

Staying Focused

OIG's hospice findings come back to the same themes: document why each patient is terminally ill, support every higher level of care, and follow technical requirements. Getting these right protects patients and the hospice alike.

Final Tip

Keep a file of OIG hospice reports relevant to your services, and review it each year when planning internal audits.

Remember the Appeal Rights

If a contractor issues an overpayment demand based on OIG findings, the hospice keeps its full Medicare appeal rights.

Key Takeaways

• OIG's hospice Work Plan includes active compliance audits, high-risk general inpatient audits, cap calculation reviews, and new enrollment analysis.

• Recent audits found unsupported terminal prognosis and levels of care, with multimillion-dollar estimates.

• OIG typically samples 100 claims and extrapolates results.

• Recommendations often extend to claims outside the audit period under the 60-day rule.

• Internal audits, training, and a ready response process reduce risk.

Building an OIG Readiness Program

• Assign responsibility for monitoring the Work Plan and new OIG reports.

• Compare OIG findings with your own audit results.

• Conduct annual counsel-directed sample audits in high-risk areas.

• Maintain organized records that can be produced quickly.

• Train staff on terminal prognosis and level-of-care documentation every year.

• Report readiness to the compliance committee and governing body.

Coordinating With Other Reviews

Hospices may face OIG audits at the same time as MAC, UPIC, or survey activity. Keep a central log of all reviews, deadlines, and findings, and make sure responses are consistent across reviewers.

Frequently Asked Questions

What is the OIG Work Plan?

A continuously updated list of OIG's planned and ongoing audits and evaluations.

What hospice topics are on the Work Plan?

Hospice compliance audits, high-risk general inpatient services, inpatient and aggregate cap calculations, new hospice enrollments, and other hospice-related work.

What do OIG hospice audits usually find?

Unsupported terminal prognosis, unsupported levels of care, and technical errors in certifications, elections, and face-to-face encounters.

Are OIG recommendations final?

No. CMS and its contractors decide whether overpayments exist, and hospices can appeal.

What sample size does OIG use?

Often 100 randomly selected claims, with results extrapolated to the population.

Conclusion

OIG's hospice work in 2026 continues to focus on terminal prognosis, levels of care, and documentation, with active audits of hospice compliance and high-risk general inpatient services, reviews of cap calculations, and attention to new enrollments. Recent reports show that even established, not-for-profit hospices can face multimillion-dollar extrapolated findings. Hospices that monitor the Work Plan, audit their highest-risk areas, train staff, and prepare a response process will be better positioned if OIG comes calling.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps hospices prepare for OIG audits through Work Plan monitoring, counsel-directed sample audits, terminal prognosis and level-of-care reviews, staff training, and support for records production and draft report responses. If you want to prepare for OIG scrutiny, please get in touch with us. We will be happy to help you with this topic.

References

• U.S. Department of Health and Human Services, Office of Inspector General. Work Plan. https://oig.hhs.gov/reports/work-plan/

• U.S. Department of Health and Human Services, Office of Inspector General. Review of Hospices' Compliance with Medicare Requirements (W-00-24-35783). https://oig.hhs.gov/reports/work-plan/browse-work-plan-projects/w-00-24-35783/

• U.S. Department of Health and Human Services, Office of Inspector General. Medicare Hospice Provider Compliance Audit: Hospice of the Valley - West (A-09-23-03004), July 2026. https://oig.hhs.gov/documents/audit/11821/A-09-23-03004.pdf

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

• 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/

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

• 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 Program Integrity Manual, Chapter 8, Section 8.4, Statistical Sampling for Overpayment Estimation. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c08.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

• 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