UControl Hospice Billing Services
A hospice revenue cycle process involves generating payments from Medicare, Medicaid, and commercial payers for hospice benefits using the per diem hospice benefit system. A hospice billing service handles Notice of Election submission, assigning of level of care claims, monthly sequencing of bills, coordinating room and board payments, and handling of denied bills for hospices.
UControl Billing provides its services to stand-alone hospices, hospital-based hospices, multisite hospices, and new hospices waiting to file their first Medicare claims. It provides NOEs, claim scrubbing, sequential claims, and steady per diem cash flow.
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How Hospice Billing Works
There is only one sequence for hospice billing: verify the election and certification, file the Notice of Election no later than five calendar days after the election date, submit monthly claims in the sequence, claim follow-up, select the appropriate level of care for every day, and match the payments against the per diem rates. Hospice billing is not like any other fee-for-service specialty. Hospices receive payment for their services on a per diem basis for each day that the patient is enrolled into the program, not on the basis of the cost of a particular procedure. That’s why hospice billing consists in timely filing of claims and assigning the proper level of care to each day.
The Notice of Election and the five-day rule
The Notice of Election (NOE) indicates to Medicare that the patient has elected the hospice benefit. It should be filed no later than five calendar days after the election date. Late Notice of Election creates provider-liable days, meaning that hospice will deliver care to the patient during these days and will be unable to bill for them. This one submission is the most critical component of hospice billing. The daily submission of the NOE and acceptance monitoring determine whether you get paid or have a week’s worth of non-paid time, thus making it necessary to monitor this every day instead of batching it.
Sequential and monthly billing
Hospice claims processing happens in a monthly sequence, meaning that the failure of one claim holds up all subsequent claims. This is sequential billing, and what makes it different from other medical specialties is the way that this makes the aging of the accounts receivable unique to hospice. In this case, the task of monitoring is to follow through on the T status claims. If a claim is in a T status location, it means that it is still being processed.
Certification, benefit periods, and the face-to-face
The determination that someone is eligible for hospice care comes from a physician certification that he is terminally ill and has a prognosis of six months or less in his natural disease course. Beneficiary periods will be of two 90-day periods and unlimited 60-day periods. There should be a face-to-face visit prior to starting the third benefit period. Clarification on the admission authority was made in the FY 2026 final rule. The physician in the interdisciplinary team of the hospice can admit the patient in addition to the medical director, which the final rule incorporated into the admission regulation found in Section 418.25.
Hospice Billing vs Palliative Care Billing
They belong to different worlds of billing. Hospice charges a per diem rate through the Medicare hospice benefit for someone who has chosen comfort care, whereas palliative care charges fee-for-service under Part B for people who are still looking for a cure. They have their own sets of rules, and the current page focuses on hospice billing.
The Notice Of Election Filing Schedule
Day 0
Election date. Care begins.
Day 2 to 4
File and confirm acceptance.
Day 1
NOE clock running
Day 5
Last timely-filing day.
Day 6+
Days turn provider-liable.
A Notice of Election filed after five calendar days makes every day from election to filing provider-liable, so the agency delivers care those days without payment unless an exception applies
The Four Levels Of Hospice Care And How Each Is Billed
The payment by Medicare for hospice services is determined by four different levels of care, and each level has its own revenue code, as well as its own “trigger.” These triggers include Routine Home Care, Continuous Home Care, Inpatient Respite Care, and General Inpatient Care.A level of care determination for each individual day determines how much that day gets paid; therefore, the coding process is responsible for identifying which level of care is provided to the patient on each specific day.
Hospice Levels Of Care And Revenue Codes
| Level of care | Revenue code | When it applies |
|---|---|---|
| Routine Home Care | 0651 | Routine level of care for a patient at home. Pays a high daily fee for days 1 through 60 and then pays a reduced fee after day 60. |
| Continuous Home Care | 0652 | This is crisis-level care at home to control symptoms. Needs at least 8 hours of mostly nursing care in a 24 hour period and is billed in 15 minute increments. |
| Inpatient Respite Care | 0655 | Short-term hospitalization to give the caregiver some relief. Billed for up to 5 days per visit; after day 5 it returns to routine home care |
| General Inpatient Care | 0656 | This is symptom control that can only be done at home. Of the four levels of care, this one receives the most audit attention. |
Service Intensity Add-on
The Service Intensity Add-on (SIA) will pay for RN and social worker visits on the final seven days of a patient’s life, if those visits occur during Routine Home Care. Payment will be in addition to the Routine Home Care per diem and is based on an hourly rate based on Continuous Home Care for the actual time spent on the visit up to four hours per day. Many companies do not capture this payment since they must identify the last seven days of a life and record the visit time.
Our Hospice Billing And Coding Services
We offer complete revenue cycle management for our clients’ hospices from election verification to submission of room and board, billing for physician modifiers, denial and audit responses, and tracking the cumulative cap for our client’s hospice.
| Coding Services | Description |
|---|---|
| Verification of eligibility and election | Every case starts off with insurance verification of Medicare patient status, reviewing prior hospice episodes of care and number of benefit periods used by a patient, and determining whether there is a Medicare Advantage plan. A patient who had used some of his/her benefit periods with another hospice comes in midway in the sequence, hence the need to capture that past history. This is achieved through our eligibility verification process. |
| Management of NOEs and NOTRs | The Notice of Election is filed daily, and we track each one to acceptance rather than submission alone. If the Notice of Election was late due to circumstances beyond the agency's control, we capture those circumstances and file the exception. The Notice of Termination or Notice of Revocation (NOTR) is filed once the patient moves out of the benefit period. Failure to do so interferes with admission of the patient at the next agency. |
| Hospice coding and documentation review | The hospice code is based upon the principal diagnosis of death and any other diagnoses that go along with it according to the ICD-10-CM system. There are diagnoses that are not acceptable as a principal hospice diagnosis and will cause an edit when coding is done prior to claim submission. |
| Claim submission and sequential cycle management | Monthly claims include occurrence codes, condition codes, and the Q5001 to Q5010 HCPCS codes indicating where the various levels of care were provided. The claims are submitted in chronological order to clear any T-status holds so that the sequence can proceed without delay. This ties into the claims scrubbing and claims submission process. |
| Room and board billing | If a hospice beneficiary stays in a nursing facility, Medicaid will pay for the room and board pass-through services typically at 95 percent of the nursing facility Medicaid daily rate and through the hospice. Here is where the dual eligible claims coordination takes place, as it is the point at which there must be an agreement between the hospice, the facility and Medicaid regarding the number of days. We handle the coordination of the pass-through and dual eligible coordination services so that you give better patient experience and get payment for the room and board services. |
| Physician Services Billing: GV & GW modifiers | Services rendered by the attending physician related to the terminal illness bill with the GV modifier, whereas services not related to the terminal illness bill with the GW modifier. The key is whether the physician rendering the services is the independent attending physician for the patient or is a part of the hospice as the service providers |
| Denial management, ADRs, and appeals | Denials and Reviews for Hospices revolve around several predictable issues: the late NOE, lack of adequate documentation to support the day billed, Length of Stay for General Inpatient care, live discharges, and whether something is related or unrelated. We prepare and pursue each Additional Documentation Request and appeal with the information that addresses the review. That's how we handle denial trends and claim denial support for hospices. |
| A/R Recovery and Historical Claims Review | Many agencies changing their billing partner may have historical, unreviewed claims that still contain revenue to be recovered if the timely filing period is addressed on time. Our historical claim review is an onboarding task not an after-thought. The recovery is achieved through our A/R support and recovery service, and the revenue recovered is always verified with an aging report prior to claiming. |
| Cap Management and Real-Time Reporting | The combined cap restricts the maximum annual payment per patient within one cap year. A hospice with extended Length of Stay could violate the limit and have a repayment obligation. We monitor the exposure to the cap annually so that the overpayment is discovered as a projection not as a surprise at year-end. The cap for FY 2026 is $35,361.44. |
FY 2026 Hospice Payment And Quality Changes
Changes to FY 2026 that affect hospice reimbursement include an increase of 2.6% in payments starting from October 1, 2025, the use of HOPE instrument in lieu of HIS for quality measurement, and more attention paid during audits to high-scrutiny stays. Every change has a financial implication.
The FY 2026 final rule
The FY 2026 Hospice Wage Index final rule established the payment update of 2.6%, equal to about $750 million. It consists of 3.3% market basket increase, decreased by 0.7 productivity adjustment. The aggregate cap increased to $35,361.44 from $34,465.34, and the wage index values were recalculated according to the locality. In addition, the rule allowed for returning the requirement of signatures and dating of the face-to-face attestation and placed it within the recertification form. Both changes modify what constitutes a proper package for certification.
HOPE replaced the HIS
Hospice Outcome and Patient Evaluation (HOPE) instrument replaced the Hospice Item Set beginning October 1, 2025, while the record submissions began using the iQIES system. Agencies have to submit no less than 90 percent of their records within 30 days after the assessment date in order not to be penalized. If it fails, then a 4 percentage point cut is applied and the update rate of 2.6% becomes negative 1.4%. The billing implication is immediate. The compliance with quality reporting and revenue visibility becomes a revenue protection issue. A billing partner should match the status of assessment submissions with claims, rather than keeping the billing and quality tracks separate.
Focus of Audit and Oversight
Probe and Educate Reviews, Additional Documentation Requests and Unified Program Integrity Contractor efforts pay close attention to General Inpatient stays, long lengths of stay and live discharges. The PEPPER tool provides for the self-audit capability, since the agency compares its own trends with national trends. Enhanced enrollment oversight pertains to new hospices in Arizona, California, Nevada, and Texas.
Who We Serve
UControl Billing offers hospices at every stage of development, from startups with first NOEs to enterprise agencies with a need for consolidated billing workflow among locations. The challenge associated with billing varies depending on the stage of the agency.
Pre-census Hospice Startups
Newly established hospice requires Medicare enrollment, approved first NOEs, and a billing infrastructure in place prior to the increase in census. Having the first claims submitted without mistakes ensures having a good cash flow foundation.
Scaling Growth-oriented agencies
The census growing faster than billing staff leads to a backlog and declining NOE discipline. The challenge is that billing needs to grow along with the census, not trail one quarter behind it.
Multi-location Enterprise agencies
Having a multi location agency requires having uniform billing practices and reporting. Having a single metric for all of them makes performance comparison possible and caps risk exposure.
UControl Billing addresses agency billing challenges at the relevant stage – it can provide either the first claims processing or billing consolidation among multiple locations.
AI-Powered Hospice Billing, With Humans Accountable
Automation takes charge of all the processes that are repetitive in hospice billing: checking status of claims, accepting NOEs, re-checking eligibility and detecting denial patterns. UControl certified billers make all the decisions because level of care, documentation risks, related versus unrelated and appeals are always decisions and not processes.
There lies the clear distinction: one side is responsible for watching and the other side makes decisions. The software is used by automation to watch for the NOE queue, to make eligibility rechecks based on certain schedules and to detect denial patterns quicker than any person could analyze the reports. It is the certified billers who decide on a level of care, on the nature of the services provided and on an approach to appeal.
UControl Billing provides the specialty of hospice care through its services; therefore, the agency does not have to depend on just one biller anymore
Why Outsource Hospice Billing To UControl Billing
The process of outsourcing hospice billing allows the agency to get rid of the tasks of recruiting specialized billers, maintaining NOE discipline every day, monitoring sequential claims cycle, and handling audits. The task of constant staffing is substituted by the task of a varying cost that depends on the amount of collected money.
Billing in hospice is a specific type of medical billing that requires specialized knowledge. Hospice billers are difficult to find, and even more difficult to replace. NOE has to be monitored every day, sequential clean claims cycle cannot go without removing T-statuses in proper order, and a response to ADR or UPIC audit has to be fast and documented. A single person doing this is one point of failure of the agency’s cash flow.
The internal billing department can be the solution for some agencies, and this trade-off is fair enough. An internal billing department allows for control and billers who are familiar with the patients of the agency at the expense of recruitment of specialized billers and their training in NOE and cap.
The transfer of these responsibilities to the billing outsourcing partner means that there is a team that already knows how to do the job in the hospice. All performance metrics that relate to performance are marked until verified, not copied from a competitor’s organization.
Medicare, Medicaid, and Commercial Hospice Billing
Medicare covers the vast majority of hospice claims using the per diem benefit, Medicaid adds room and board costs for nursing facility patients, and Medicare Advantage beneficiaries funnel their hospice claims into traditional Medicare. Each insurer uses its own billing process.
Medicare
The leading payer for hospice claims and the payor of the per diem payment rates, aggregate cap, and NOE and sequential billing rules. The Medicare Part A expertise forms the basis of hospice billing knowledge.
Medicare Advantage
Hospice coverage remains a traditional Medicare benefit. The VAID hospice carve-in ceased December 31, 2024, so an MA beneficiary's hospice claims go through traditional Medicare, although the MA plan can continue to be involved in other service claims.
Medicaid
Covers hospice claims using rates based on Medicare and adding the room and board pass-through for nursing facility residents. Daily payment rates and prior authorizations differ state-by-state, so the billing process reflects that of each state's Medicaid.
Commercial & VA
Commercial hospice payments are based on individual plan terms, not the Medicare per diem system. VA hospice care follows a separate authorization and billing process.
EMR and Hospice Software Compatibility
Unlike many competitors, UControl Billing functions within the agency’s EMR system, without requiring any platform switch. Hence, switching the billing partner doesn’t require the agency to switch its systems.The risk of switching cost keeps the agencies that have a poor-performing biller from changing their billing partners. UControl Billing will function inside the agency’s current EMR system, pulling the necessary information for billing purposes, including the days that have been billed. This process is done within the EMR systems that are already being used by the hospice agency.
- WellSky
- Netsmart
- MatrixCare
- KanTime
- Axxess
How Onboarding Works
The onboarding process takes a hospice from the assessment phase to the go-live phase in five specific phases that are scheduled in such a way that there will be no lapsing of the NOE and the billing cycle is always open.
Assessment and payers' inventory
At this phase we look at all the claims, denials, and payers for scoping purposes.
EMR access and process mapping
Access to the existing EMR and NOE/claim process mapping is established.
Aging A/R review
Decide whether you want to handle the open claim status until their timely filing period expires.
Parallel run
The new claims process starts working, with NOE handoff date being set.
Go Live
This means moving the whole billing to our process with reporting cycles being defined.
Medical Billing Certifications and Compliance Standards
We hold the certifications that payers and auditors look for, and our coders carry the right credentials. It’s not the most exciting part of the work, but it’s the part that keeps your claims on solid ground.
Explore Frequently Asked Questions
Hospice billers generate claim reimbursement by transforming hospice care into claims through the per diem benefit program under Medicare hospice benefit. These tasks include Notice of Election submission, level of care determination, monthly billing in sequence, A/R support, room & board coordination, and denial follow-up for hospices.
Notice of Election informs Medicare about the choice of patients to use the hospice benefit. This notice must be delivered to the contractor within five days after the date of election. If late, then the days between election and submission will make the provider responsible; therefore, the agency provides hospice services on those days without any reimbursement unless there is an exception.
There are four levels of hospice care which include Routine Home Care (revenue code 0651), Continuous Home Care (0652), Inpatient Respite Care (0655), and General Inpatient Care (0656). All these levels get billed for each enrolled day and are well documented.
With sequential billing, the claims of hospice will be processed on a month-to-month basis. Each claim that is rejected or stuck will cause problems to all other subsequent claims. This is the reason why the age of hospice claims is unique and why T-status is critical for their processing.
The GV modifier refers to an attending physician's services related to the terminal illness of a patient, rendered by a non-hospice physician. The GW modifier refers to services that do not relate to the terminal illness. These modifiers show Medicare what the relationship between the physician's service and hospice election is.
When hospice patients reside in nursing facilities, the Medicaid payment for room and board is made as a pass-through through the hospice, usually at 95% of the daily Medicaid rate charged by the facility. Coordinating the days across the hospice, the facility, and Medicaid is where dual-eligible claims break.
Not at all. It’s a traditional Medicare benefit even for beneficiaries of MA plans. The pilot program for VBID that tried out MA hospice coverage ceased operations by December 31, 2024; hence, all claims by MA enrollees will be paid under traditional Medicare.
Aggregate cap means the upper limit of annual Medicare payment for one hospice by each beneficiary during cap year. Long average lengths of stay at a hospice allow it to breach the cap and return the excess amount. The cap amount for FY 2026 is $35,361.44.
HOPE, an abbreviation for the Hospice Outcomes and Patient Evaluation instrument, superseded HIS on October 1, 2025, by submitting it via iQIES. Failure to meet the 90 percent timely submission threshold means a 4 percentage point reduction of payment; hence, quality reporting became revenue-protecting for hospices.
The billing of a hospice is usually charged either at a percent of patient collections or per patient per month rate, being the native structures of the billing specialty. To make the right choice based on the census, payer mix and scope, the most relevant price will be provided in a quote for your agency.