Hospice Billing Explained: Modifiers, Insurance Rules, and Common Pitfalls
Hospice billing can be frustrating—especially if you’re unsure where to send claims or why they’re getting denied. If you’ve struggled with modifiers, rejections, or insurance confusion, you’re not alone. This guide breaks down hospice billing so you can avoid costly mistakes and get paid faster.
Key Takeaways
- Hospice billing requires knowing who pays for what—Medicare, Advantage Plans, or supplement insurance.
- Modifiers GV and GW are essential to prevent denials when billing for hospice patients.
- Medicare covers hospice-related conditions, while unrelated conditions are billed to Part B or Advantage Plans.
- Incorrect billing leads to automatic denials—always verify hospice status before submitting claims.
- Appeals are common—understanding the denial reason and resubmitting with corrections is crucial.
Hospice Billing: Who Is Responsible for What?
First things first—hospice billing is not the same as billing for hospice services. Many people get this mixed up. If you run a hospice service, you’re billing for the actual hospice care. But what we’re talking about here is how to bill when you’re a provider seeing a patient who is already on hospice.
Why This Matters
When a patient is enrolled in hospice, their medical care is generally covered under hospice insurance, but only for conditions related to their hospice diagnosis. If the patient receives treatment for an unrelated condition, that service may need to be billed differently.
For example:
| Patient Diagnosis | Condition Being Treated | Who Pays? |
|---|---|---|
| Congestive Heart Failure | UTI | Medicare Part B (or Advantage Plan) |
| Terminal Cancer | Chemotherapy | Hospice Insurance |
| Alzheimer’s | Skin Infection | Possibly Hospice Insurance (depending on documentation) |
This is where things get messy. If you bill the wrong insurance or fail to use the right modifiers, your claim will likely get denied.
Hospice Billing: Understanding Modifiers
If you’re billing for a patient who is on hospice, you must use the correct modifiers to indicate whether the treatment is related to the hospice diagnosis or not.
Here’s how it works:
- Modifier GV – Used when a non-hospice provider is treating a patient for a condition related to their hospice diagnosis.
- Modifier GW – Used when a non-hospice provider is treating a patient for a condition unrelated to their hospice diagnosis.
If the condition is related to hospice, the claim typically goes to Medicare (not the patient’s Advantage plan). If it’s unrelated, then it’s billed to Medicare Part B, an Advantage Plan, or a supplement plan.
Where to Send Hospice Billing Claims
Hospice billing also depends on which insurance the patient has. The most common scenario is that the patient is on Medicare hospice coverage, but there are exceptions.
- If the service is related to the hospice diagnosis → Bill Medicare (not their Part C plan).
- If the service is unrelated to the hospice diagnosis → Bill Medicare Part B, an Advantage plan, or a supplement plan.
Things get complicated if the patient is on an Advantage Plan (like Blue Cross Blue Shield Advantage, AARP Advantage, etc.). If the service is hospice-related, you should bill straight Medicare, not the Advantage Plan.
Hospice Billing: Workflows, Common Mistakes, and Best Practices
Now that we’ve covered the basics of hospice billing, let’s dive into the workflows you need to have in place, common billing mistakes to avoid, and some best practices to ensure you get paid without frustrating delays.
Setting Up a Smooth Hospice Billing Workflow
One of the biggest challenges with hospice billing is keeping track of which patients are on hospice, what their primary diagnosis is, and where the claims should go. If you don’t have a clear internal workflow, things will slip through the cracks—leading to claim rejections, delays, and lost revenue.
Verify Hospice Enrollment Before Each Visit
Many providers don’t find out that a patient has been admitted to hospice until after they’ve already provided services. That’s a problem because if you submit a claim without knowing the patient’s hospice status, it’s likely going to get denied.
A good workflow should include:
- Checking before the visit whether the patient is on hospice
- Confirming which hospice provider they are enrolled with
- Determining whether the visit is related or unrelated to the hospice diagnosis
If you see patients in long-term care facilities, you should set up a system where facility staff notifies you immediately when a patient enters hospice care.
Use the Correct Modifiers Every Time
If you’re billing a service for a Medicare hospice patient, using the wrong modifier can mean an automatic denial.
- Use Modifier GV → When a non-hospice provider treats a hospice-related condition
- Use Modifier GW → When a non-hospice provider treats a condition unrelated to hospice
For example, if a patient is on hospice for cancer but you’re treating them for hypertension, you need to use modifier GW to show that the condition is not related to their hospice care.
Submit Claims to the Right Place
One of the most frustrating parts of hospice billing is figuring out where to send claims. Here’s a simple guide:
| Scenario | Who to Bill? |
|---|---|
| Hospice-related condition | Medicare (not Advantage Plan) |
| Unrelated condition | Medicare Part B or Advantage Plan |
| Patient has a supplement plan | Bill supplement plan after Medicare |
If a patient has an Advantage Plan (like Humana, Aetna, or Blue Cross Blue Shield Advantage) but the service is hospice-related, it should not go to their Advantage Plan. Instead, it should be billed straight to Medicare.
The ABCDs of Medicare: A Simplified Guide
Common Hospice Billing Mistakes (And How to Avoid Them)
Even experienced billers make hospice billing mistakes that can result in denied claims, lost revenue, and wasted time. Here are some of the most common errors:
Not Knowing a Patient Was Admitted to Hospice
If you don’t know a patient is on hospice, you won’t use the right modifiers or send claims to the correct insurance provider. Always verify hospice status before billing.
Sending Hospice-Related Claims to an Advantage Plan
If a service is related to a hospice diagnosis, it must go to straight Medicare—not an Advantage Plan. Billing the wrong insurance will result in denials and delays.
Forgetting the Correct Modifiers
Using the wrong modifier (or forgetting it completely) means automatic claim rejection. Make sure your billing team double-checks every claim before submitting it.
Ignoring Rejections and Denials
If a claim gets rejected, you must fix and resubmit it quickly. The longer you wait, the longer it takes to get paid. Setting up a system to track denials and rejections can help avoid cash flow problems.
Best Practices for Getting Paid Faster
If you want hospice billing to run smoothly and avoid constant denials, here are a few best practices to implement:
Train Your Team on Hospice Billing Rules
If your biller doesn’t understand how hospice claims work, they’ll make costly mistakes. Provide ongoing training so they know:
- Which claims should go to Medicare vs. an Advantage Plan
- When to use modifier GV vs. GW
- How to handle rejected claims quickly
Build Strong Communication With Hospice and Facilities
If you see patients in nursing homes or assisted living, make sure you have a system where facility staff informs you immediately when a patient enters hospice care.
Review Your Denials and Fix Common Issues
If your claims keep getting denied, figure out why. Keep track of common mistakes, and fix them so they don’t keep happening.
How to Appeal Denied Hospice Billing Claims
Even if you do everything right, insurance companies still deny claims. If that happens, don’t panic—appealing is part of the process. Here’s what you need to do:
Step 1: Identify Why the Claim Was Denied
Most insurance providers will include a denial reason code on the Explanation of Benefits (EOB). Some common reasons for hospice billing denials include:
- Missing or incorrect modifiers (GV/GW)
- Claim sent to the wrong payer (Medicare vs. Advantage Plan)
- Patient not showing as hospice-enrolled in the system
- Duplicate claims submitted
Step 2: Correct the Mistake and Resubmit
Once you identify the error, fix it and resubmit the claim. This might involve:
- Adding the correct modifier (GV or GW)
- Sending the claim to Medicare instead of an Advantage Plan
- Providing additional documentation to support the claim
Step 3: Follow Up Until the Claim is Paid
Don’t assume your appeal was processed—follow up! Call the payer if needed and keep track of appeal deadlines.
How to Prevent Hospice Billing Issues in the Future
Implement a Billing Review Process
Before submitting claims, make sure your billing team reviews them for errors. A second set of eyes can catch missing modifiers, incorrect payer info, or duplicate submissions.
Use a Billing Software That Flags Hospice Patients
If your billing system doesn’t alert you when a patient is on hospice, you’re going to have claim issues. Look for billing software that integrates with hospice databases to flag these patients before you submit claims.
Set Up a Communication System With Hospice Providers
Many billing issues happen because providers don’t know a patient was enrolled in hospice. Work with hospice agencies and long-term care facilities to get notified immediately when a patient enters hospice care.
Keep Track of Common Denials and Adjust Your Workflow
If you keep seeing the same rejections, fix your internal processes. Keep a log of denials and use it to improve future billing.
FAQ: Hospice Billing
Hospice billing can be confusing, and you probably still have questions. Below are some of the most frequently asked questions about hospice billing, along with clear, simple answers to help you avoid mistakes and get paid faster.
What is hospice billing?
Hospice billing refers to how providers bill for services when treating patients who are enrolled in hospice. This is different from hospice services billing, which is when a hospice agency bills for providing hospice care.
If you’re a provider seeing a hospice patient, you need to:
- Determine if the service is related to their hospice diagnosis
- Use the correct modifiers (GV or GW)
- Send claims to the right insurance (Medicare vs. Advantage Plan)
Who pays for hospice-related services?
If a service is related to the patient’s hospice diagnosis, the claim should go to Medicare (not their Advantage Plan).
If the service is unrelated to hospice, it should be billed to:
- Medicare Part B
- Their Advantage Plan (if they have one)
- Their Supplement Plan (if applicable)
What are the hospice billing modifiers?
To bill correctly, you need to use one of two modifiers:
| Modifier | When to Use It? |
|---|---|
| GV | When a non-hospice provider treats a hospice-related condition |
| GW | When a non-hospice provider treats a condition unrelated to hospice |
Using the wrong modifier (or forgetting one) can result in claim denials.
What happens if I bill a hospice-related claim to an Advantage Plan?
Your claim will get denied. Medicare Advantage Plans do not cover services related to a patient’s hospice diagnosis. These claims must be sent to traditional Medicare.
How do I know if a patient is on hospice?
Before billing, always verify if the patient is enrolled in hospice. You can check by:
- Contacting the facility staff (if they are in a nursing home or long-term care)
- Checking the patient’s Medicare eligibility online
- Calling the hospice provider directly
If a patient is newly admitted to hospice and you weren’t informed, this could cause claim denials and delays.
Can I bill for a patient on hospice if the service is unrelated to their hospice diagnosis?
Yes, but you must:
- Use modifier GW to indicate the service is not related to hospice
- Send the claim to Medicare Part B or the patient’s Advantage Plan
If you forget the GW modifier, the claim might be denied because the system will assume it was a hospice-covered service.
What do I do if my hospice billing claim gets denied?
Follow these steps to appeal the denial:
- Check the reason for denial on the Explanation of Benefits (EOB).
- Fix the error (e.g., add the correct modifier, change the payer).
- Resubmit the claim with the corrected information.
- Follow up with the payer to ensure the claim gets processed.
Keeping track of denials and rejections helps you identify patterns and prevent future errors.
How do I make sure I’m billing hospice patients correctly?
To avoid denials and delays, follow these best practices:
- Verify hospice enrollment before every visit
- Use GV/GW modifiers correctly
- Send claims to the right payer (Medicare vs. Advantage Plan)
- Train your billing team on hospice billing rules
- Monitor claim denials and fix recurring mistakes
Final Thoughts on Hospice Billing
Hospice billing isn’t easy, but with the right workflow, correct modifiers, and proper communication, you can reduce denials and get paid faster. The key is to verify hospice enrollment, send claims to the right place, and stay on top of appeals.