Medicare contractors reviewing a hospice claim rarely start with the billing codes. They start with the plan of care and the visit notes behind it. Under 42 CFR 418.56, the hospice interdisciplinary group must write a plan of care that states the exact scope and frequency of nursing, aide, social work, and counseling services a patient will receive, then review that plan no less often than every 15 calendar days. A Recovery Audit Contractor (RAC), Unified Program Integrity Contractor (UPIC), or Medicare Administrative Contractor (MAC) opening a hospice file compares that stated frequency against what the visit notes actually show. This pattern fits inside the broader mechanics of a Medicare audit, but the specific checkpoints come from the hospice conditions of participation themselves.
How Auditors Read the Plan of Care
Section 418.56(c) requires the plan of care to include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, alongside interventions for pain and symptoms, measurable outcomes, and the drugs and medical supplies the hospice intends to provide. That requirement sets the benchmark an auditor applies later. A reviewer pulls the visit schedule the plan promised, lines it up against the clinician's visit notes and the hospice's level-of-care documentation, and separately checks the file's prognosis support against the applicable local coverage determination, flagging any interval where the promised frequency and the delivered care diverge. That gap becomes the documentation failure the auditor cites against the claim.
The Interdisciplinary Group's 15-Day Review
Section 418.56(a) requires the interdisciplinary group to include a physician, a registered nurse who coordinates care, a social worker or counselor, and a pastoral or other counselor. Under section 418.56(d), that same group, working with the attending physician, must review, revise, and document the plan of care as frequently as the patient's condition requires, but no less frequently than every 15 calendar days, noting the patient's progress toward the plan's stated goals. An auditor checks two things separately: whether that review happened on schedule, and whether the resulting plan was revised to match the patient's condition. A plan that sits unchanged across several 15-day cycles while the patient's needs are shifting fails that standard.
Missed Visits and the Documentation Gap
The hospice must also maintain, under section 418.56(e), a system ensuring that care and services are provided in accordance with the plan of care and that information about each visit is shared across disciplines. Auditors treat an undocumented missed visit, one where the record does not describe why the visit was missed or what the clinician did to resolve it, as a deficiency in its own right. Visit notes with dates, disciplines, or care descriptions that do not match the physician's orders or the plan of care draw the same scrutiny, regardless of whether the underlying care was appropriate.
Health Law Alliance's attorneys have overseen 2,000+ audits and handled 5,000+ matters, with 25+ years of experience.
A plan of care that promises a visit frequency the record cannot support becomes the auditor's overpayment finding.
What a Visit-Frequency Finding Can Trigger
A single missed or undocumented visit is a chart correction. The same gap repeated across a sample of claims becomes an extrapolated overpayment rather than one confined to the claims actually reviewed. The hospice then faces a recoupment demand it can challenge. The correct route, a claim reopening or a formal appeal, depends on the stage of the matter and the contractor involved; see HLA's guide to Medicare claim reopenings versus appeals for which one applies.
Why Early Legal Counsel Is Critical
It is critical that hospice providers promptly retain experienced healthcare defense counsel upon receiving an audit notice, an additional documentation request, or any other program integrity inquiry concerning visit frequency or plan of care compliance. Early legal intervention can protect the provider's rights, help ensure appropriate responses to contractor requests, avoid inadvertent admissions, preserve relevant defenses, and allow counsel to communicate with auditors on the provider's behalf. Delaying legal representation can significantly affect the outcome of a matter and expose the provider to unnecessary risk.
How Health Law Alliance Can Help
Health Law Alliance defends hospice and home health providers in Medicare audits nationwide. If your hospice has received an audit notice citing visit frequency, interdisciplinary group review, or plan of care documentation, contact Health Law Alliance's Hospice & Home Health Audit Defense attorneys for a free, confidential consultation.
