OIG report finds 45 of 100 sampled new hospice enrollments fell short, and opens a home health admission-source audit

Two pieces of work from the HHS Office of Inspector General (OIG) concern hospice eligibility and home health billing. One is a finished hospice audit with an open recommendation. The other is an active home health audit with no findings yet.

Hospice: new enrollees with no hospital or ER history

In report A-06-22-09003, issued June 18, 2026, OIG assessed whether Medicare payments for fiscal year 2021 hospice services met Medicare requirements for a specific group: new hospice enrollees with no inpatient or emergency room claims in the 18 months before they started hospice.

What OIG found. Of the 100 initial certification periods it reviewed, the documentation for 45 didn't meet Medicare hospice requirements:

• For 21 periods, the clinical information in the medical records didn't support that the enrollee had a terminal illness, resulting in $251,067 in unallowable payments, OIG says.
• For 24 periods, the medical records didn't meet hospice eligibility documentation requirements, resulting in $294,432 in unallowable payments.

Based on its sample, OIG estimated that Medicare could have saved $255.1 million in hospice claim payments for the new enrollees in its sampling frame if the hospice Medicare Administrative Contractors (MACs) had eligibility review procedures for enrollees without inpatient or ER claims in the prior 18 months.

What OIG recommended. OIG recommended that CMS work with hospice MACs to consider this a high-risk area in eligibility reviews and possibly develop pre- or postpayment review procedures for these enrollees. CMS concurred. OIG lists the recommendation (26-A-06-077.01) as "Open Unimplemented," with an update expected December 17, 2026.

What to watch. We haven't found any MAC announcing a new review based on this recommendation. OIG's two categories of findings show what it looked for in the sample: whether the clinical record supports a terminal illness, and whether the records meet eligibility documentation requirements. OIG's report summary describes the hospice benefit as for enrollees "with a life expectancy of 6 months or less."

Home health: occurrence codes 61 and 62

OIG's work plan lists an active nationwide audit, OAS-26-05-056, announced April 23, 2026.

Under the Patient-Driven Groupings Model (PDGM), which assigns 30-day periods to one of 432 case-mix groups, admission source is one of five variables. Agencies use occurrence codes 61 and 62 to show an institutional stay within 14 days before the home health admission. OIG says institutional admissions result in higher reimbursement than community admissions. OIG notes that agencies may report institutional admissions with these codes even when no corresponding Medicare inpatient claim exists.

OIG says earlier audits found agencies billing institutional admissions incorrectly using these codes, sometimes based on emergency room visits or observation stays that do not qualify as inpatient stays. This audit will determine whether claims billed with codes 61 or 62 were submitted in line with Medicare's source-of-admission billing and coding requirements. OIG says it will assess the documentation supporting admission source and identify vulnerabilities that allow improper payments.

The work plan lists the audit as active. It has no findings yet, and OIG gives no completion date.

Related: FY 2027 hospice payment rates and cap · Medicare jurisdictions tracker

Sources

• HHS-OIG, A-06-22-09003
• HHS-OIG Work Plan, OAS-26-05-056

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It is general information, not clinical, billing or legal advice.*

Drafted with AI assistance from primary sources and reviewed by Monsaur Othman before publication. Read how we use AI, our editorial policy and our corrections policy.

Informational only, not billing, legal or clinical advice. Check the linked primary source and your Medicare Administrative Contractor.