Hospice care is a specialized approach focused on providing comfort and quality of life for individuals facing a life-limiting illness. It shifts the focus from curative treatments to palliative care, managing symptoms and offering emotional and spiritual support. For hospice care to begin and be covered by insurance, specifically the Medicare Hospice Benefit, a physician must formally certify the patient’s eligibility.
The Two-Part Requirement: Referral and Certification
The process of beginning hospice care involves two distinct actions: a referral and a certification. A referral is the initial step that can be started by almost anyone, including the patient, a family member, a caregiver, a social worker, or a hospital discharge planner. This referral is essentially a request for a hospice agency to evaluate the patient for admission.
The referral prompts the hospice agency to assess the patient’s condition and needs to determine if they meet the necessary medical criteria for services. This initial action does not legally or financially authorize the start of care under the hospice benefit.
The certification is the formal, legal step that must be completed by a physician to establish eligibility for the Medicare Hospice Benefit and similar insurance plans. This certification is often referred to as the “doctor’s order” and is required before the hospice can submit claims for payment. The patient’s attending physician and the hospice medical director must both sign this initial certification.
Understanding this distinction is important for families, as they do not need to wait for their doctor to initiate the conversation; they can proactively contact a hospice agency themselves to prompt the eligibility assessment. The doctor’s involvement is mandatory, but only at the certification stage, which formalizes the patient’s admission into the program.
The Physician’s Role in Establishing Eligibility
The physician’s role in establishing hospice eligibility is legally defined and centers on confirming a specific medical prognosis. The foundation of the certification is the professional medical judgment that the patient is terminally ill. This means the physician must attest that the patient has a life expectancy of six months or less if the illness runs its normal course.
This determination is a clinical assessment, not a prediction of death, based on the progression of the patient’s primary diagnosis and related conditions. The physician considers factors like disease-specific criteria, declining functional status, and increasing reliance on assistance with daily activities. A brief narrative explaining the clinical findings that support the six-month prognosis is a required part of the certification documentation.
For the initial certification, two physicians must sign the document: the patient’s attending physician (if they have one) and the hospice medical director or a physician member of the hospice team. The attending physician is chosen by the patient to oversee their medical care. This dual-signature requirement ensures a consensus on the terminal prognosis and serves as the legal gateway for the patient to access covered hospice services.
The certification must be obtained by the hospice agency within two calendar days after the start of care, although a verbal certification can be obtained initially if the written documentation takes longer. This strict requirement, outlined in regulations such as Title XVIII of the Social Security Act, authorizes coverage under the Medicare Hospice Benefit.
Re-certification and Continuation of Care
The initial certification is not permanent, as the patient’s eligibility must be periodically re-confirmed to maintain hospice coverage. The Medicare benefit is structured into specific benefit periods. The first two benefit periods are 90 days each, followed by an unlimited number of subsequent 60-day periods.
To continue care beyond the current period, the patient must be re-certified by a physician at the start of each new benefit period. This involves a renewed medical determination that the patient continues to meet the six-month or less prognosis. For re-certifications, only the hospice medical director or a hospice physician is required to sign the document, unlike the initial certification that requires two signatures.
Starting with the third benefit period, a face-to-face encounter between the patient and a hospice physician or nurse practitioner is mandatory before re-certification. This visit must occur no more than 30 days before the new period begins and provides up-to-date clinical findings to support the continued terminal prognosis. This process ensures patients who live longer than six months can still receive continuous care, provided the medical criteria are met.