A hospice recertification is not complete without a timely face-to-face encounter, and Medicare treats a missed one as a failed recertification, not a paperwork gap. Starting with a patient's third benefit period, and every benefit period after it, a hospice physician or hospice nurse practitioner must see the patient in person no more than 30 calendar days before the recertification is signed. Miss that window, and the patient ceases to be eligible for the Medicare hospice benefit for that period, and the hospice must keep treating the patient at its own expense until the encounter happens. The rule sits at 42 CFR 418.22 and is detailed in the Medicare Benefit Policy Manual, Chapter 9, Section 20.1.
The 30-Day Timing Rule
The face-to-face encounter requirement begins with a patient's third benefit period and continues for every recertification after it; there is no encounter requirement for the initial 90-day period or the first recertification. The visit must occur no more than 30 calendar days before the recertification, and it may happen as late as the first day of the new benefit period and still count as timely. CMS allows one documented exception for a patient newly admitted already in a third or later benefit period, such as an emergency weekend admission or a CMS systems outage: an encounter within two days after admission is still timely. Outside that narrow exception, the 30-day window is the only timing the manual recognizes.
Who May Perform the Encounter
Only two categories of practitioner can perform the encounter: a hospice physician, meaning one employed by or under contract with the hospice, or a hospice nurse practitioner, who must be a W-2 employee rather than a contractor. Physician assistants and the patient's outside attending physician are not authorized to perform it, and no other non-physician practitioner category qualifies under Section 1814(a)(7)(D)(i) of the Social Security Act. A nurse practitioner can conduct the visit, but cannot certify or recertify the patient as terminally ill; that signature belongs to a medical doctor or doctor of osteopathy, ordinarily the hospice medical director or the physician member of the hospice interdisciplinary group.
The Attestation Requirement
The practitioner who performs the encounter must attest in writing that the visit happened, including its date, and sign and date that attestation. The attestation can live in a distinct, clearly titled section of the recertification, in an addendum to it, or in a signed and dated clinical note that plainly documents the visit and the date. If a nurse practitioner, or a hospice physician who is not the certifying physician, performed the encounter, and the attestation is that distinct section or addendum, it carries one more requirement: it must state that the clinical findings from that visit were given to the certifying physician for use in the eligibility decision. An attestation missing that handoff language is as incomplete as one missing a signature.
Why a Missed or Late Encounter Denies the Whole Period
A recertification without a timely, properly attested encounter is not a recertification Medicare will pay for. A hospice review can arrive through the Targeted Probe and Educate program or a full RAC audit, but either way an untimely encounter costs the entire benefit period, not one line item, because the certification was not complete. Reviewers apply the local coverage determination for hospice documentation (see also Local Coverage Determinations: How MACs Use LCDs in an Audit) when checking whether the clinical record supports the certification, and a sampled finding of untimely encounters routinely gets carried across the lookback period through extrapolation, turning a handful of flagged files into a recoupment demand that starts accruing interest before any appeal is decided. CMS expects the hospice to discharge the patient from the benefit once it discovers the gap, continue the patient's care at its own expense, and re-admit the patient only once a compliant encounter occurs and a new election is filed.
Failure to meet the face-to-face encounter requirement is a failure to meet the patient's recertification of terminal illness eligibility requirement, not a documentation footnote.
Why Early Legal Counsel Is Critical
It is critical that hospices promptly retain experienced healthcare defense counsel upon receiving an audit notice, a documentation request, or any other government inquiry into recertification or face-to-face compliance. Early legal intervention can protect the hospice's rights, confirm which encounters were timely and properly attested, and preserve defenses that are only available before an extrapolated recoupment demand is finalized. Delaying legal representation can significantly affect the outcome of a matter and expose the hospice to unnecessary risk.
Health Law Alliance's attorneys have overseen 2,000+ audits and handled 5,000+ matters, with 25+ years of experience.
How Health Law Alliance Can Help
Health Law Alliance represents hospices nationwide against Medicare Administrative Contractor and RAC review of recertification files. If your hospice is responding to an audit of face-to-face compliance, contact Health Law Alliance's hospice and home health audit defense attorneys for a free, confidential consultation.
