Continuous home care is the most expensive of the four Medicare hospice levels of care. Continuous home care exists only for nursing-predominant care at home during a brief period of crisis, not extended support that happens to run long. A hospice that bills continuous home care without the hour count, the staffing mix, and the crisis documentation Medicare requires risks more than a single denied claim. Unsupported continuous home care days across a sample can support extrapolation, turning a handful of denials into a demand covering the entire audit period.
What Continuous Home Care Requires
A continuous home care day, under 42 CFR 418.302(b)(2), is a day on which a hospice patient is not in an inpatient facility and receives hospice care consisting predominantly of nursing care on a continuous basis at home. Hospice aide or homemaker services may supplement that nursing care; they cannot substitute for it. The regulation confines the level to a period of crisis, defined at 42 CFR 418.204(a) as a period in which the patient requires continuous care to achieve palliation and management of acute medical symptoms. Outside that window, the same visits are routine home care, paid at a materially lower rate, and the distinction has to be built into the clinical record while the crisis is happening, not reconstructed afterward.
The Hour Count Reviewers Check First
The Medicare Benefit Policy Manual, chapter 9, section 40.2.1, sets the operating rule: a hospice must furnish a minimum of 8 hours of nursing, hospice aide, or homemaker care in a 24-hour day beginning and ending at midnight; the hours do not need to run back to back. Within that minimum, more than half the hours must be direct nursing care from a registered nurse, licensed practical nurse, or licensed vocational nurse. If aide hours ever exceed nursing hours, the day is denied as continuous home care and paid as routine home care instead. The manual excludes charting, care-plan revision, and aide supervision from that count; those are administrative tasks. Medicare Administrative Contractors conduct this review. A RAC's postpayment review generally excludes claims a MAC has already reviewed, and the Unified Program Integrity Contractor, whose authority traces back to the Zone Program Integrity Contractors, examines continuous home care billing separately as part of its own fraud, waste, and abuse investigations.
Justifying the Period of Crisis
Passing the hour count is necessary but not sufficient. The record still has to show why the crisis existed and why it required a nurse rather than a lower level of care. CMS guidance works through recurring patterns: a caregiver who has been managing the patient and becomes unwilling or unable to continue, a sudden symptom change such as new seizures or escalating dyspnea, or a rapid decline toward imminent death. In each pattern, the hours that count toward continuous home care are hours of actual skilled intervention, assessing the patient, administering or adjusting medication, teaching a caregiver a new task, not hours a clinician was simply present or on call. A record that documents presence without documenting intervention hands a reviewer the hour count and nothing to justify it.
A continuous home care day that cannot show more than half its hours as direct nursing care is routine home care billed at the wrong rate.
When a reviewer reclassifies enough continuous home care days to routine home care, the resulting overpayment follows the same collection path as any other Medicare demand, up to and including a Treasury referral of an unpaid Medicare overpayment if it goes unresolved long enough. A hospice weighing its options before that point should also know that a waiver of recovery and limitation on liability can apply in narrow circumstances.
Why Early Legal Counsel Is Critical
It is critical that hospices promptly retain experienced healthcare defense counsel upon receiving a continuous home care medical review request, an additional documentation request, or any other audit inquiry. Early legal intervention can protect the hospice's rights, ensure the record is assembled to show both the hour count and the clinical basis for the crisis, avoid inadvertent admissions, preserve relevant defenses, and allow counsel to communicate with the reviewing contractor on the hospice's behalf. Delaying legal representation can significantly affect the outcome of a matter and expose the hospice to unnecessary recoupment and extrapolation risk.
How Health Law Alliance Can Help
Health Law Alliance's attorneys have overseen 2,000+ audits and handled 5,000+ matters, with 25+ years of experience. Continuous home care review is one piece of a broader Medicare audit defense practice covering every hospice and home health level of care. If your hospice is facing a continuous home care medical review, an additional documentation request, or a reclassification to routine home care, contact our hospice and home health audit defense team for a free, confidential consultation.
