A hospice agency’s guide to understanding COP and CFP

As hospice care has evolved, so has a regulatory framework to ensure that hospice services meet certain standards. Two key components of this framework are the Conditions of Participation (CoP) and the Conditions for Payment (CfP). They serve different purposes and have different implications for care delivery and reimbursement. The consequences of missing any of the conditions can include survey issues and claim denials.

Understanding Conditions of Participation

Conditions of Participation outline federal regulations that healthcare providers, including hospice organizations, must meet in order to participate in Medicare and Medicaid programs. The CoP ensure that hospice care adheres to minimum quality standards to protect the patients’ health and well-being.

The CoP form the foundation for being able to bill Medicare. Accrediting organization standards may include additional requirements. State and federal agencies monitor compliance with the CoP through surveys and inspections.

Protocols and interpretive guidelines (IGs) are used to conduct surveys and ensure compliance with regulatory guidelines. The IGs serve as interpretations or guidance—all the mandatory requirements for hospices are set forth in the Social Security Act and Code of Federal Regulations (CFR).

Key components of the CoP include patient rights, initial and comprehensive assessments, interdisciplinary (IDG) care planning and coordination. Other aspects include infection control requirements, hospice aide and homemaker services, short term inpatient care provisions, Medical Director requirements, and conditions related to SNF or nursing facility patients. The CoP address eligibility, what constitutes a valid election, QAPI programs, core services, licensed and professional services, organization an administrative services, governing bodies, and other requirements.

Providers that fail to meet these standards face penalties, including the loss of Medicare and Medicaid certification, which can seriously hinder their ability to operate. The 2025 Hospice Final Rule clarified the CoP related to certifying physicians to include IDG physicians as well as Medical Directors and physician designees.

Understanding the Conditions for Payment

Conditions for payment overlap with the CoP in some respects but also stand distinct from the CoP. Conditions for payment define the criteria that determine whether hospice providers will receive reimbursement for services rendered to Medicare and Medicaid patients. Medicare policy defines what can be billed. Documentation is key—Hospices must maintain comprehensive records that demonstrate compliance with regulatory requirements, such as:

• Hospice eligibility, including medical necessity. Eligibility must be supported by the initial admission documentation, as well as documentation supporting the ongoing appropriateness of hospice care. Services must be reasonable and necessary for the palliation and management of the terminal illness. Eligibility is an area of overlap between the CoP and CfP.

• A valid Election with all the required elements present, such as the name of the hospice, the effective date, confirmation that the patient understands the nature of hospice care and the impact on their Medicare benefits, designation of an attending physician, information on individual cost sharing for hospice services and the right to receive an addendum with noncovered services, information on BFCC-QIO advocacy and contact info, and a valid signature.

• Plan of Care (POC). An individualized plan of care must be established before hospice care is provided, based on the information gathered during the initial nurse assessment. Services delivered must be aligned with the POC, and the POC must be updated regularly and reflect the goals of the patient/family.

• Certification of Terminal Illness (CTI), conforming to all the requirements such as timing, life expectancy, clinical findings and documentation, physician narrative (including placement relative to the signature), attestation, and physician signature. While the CoP discusses what constitutes a valid certification of terminal illness, the CfP requires a valid CTI before a hospice can submit claims.

• Face-to-face encounters for the third and subsequent benefit periods with an attestation and clinical findings that support ongoing eligibility.

A hospice can offer great quality, but unless the documentation supports billing, it cannot be reimbursed for the care provided.

One recent change to the hospice conditions for payment occurred in 2024, requiring that certifying physicians, including hospice physicians and hospice attending physicians, be enrolled in or opted-out of Medicare in PECOS in order for hospice claims to be paid.

Differences Between CoPs and CfPs

Understanding the differences between the Conditions of Participation and Conditions of Payment is essential for hospice leaders. Both frameworks work together to shape the quality and financial viability of hospice care.

The primary distinction between Conditions of Participation and Conditions for Payment lies in their focus. The CoP are regulatory in nature and emphasize the quality and standards of care provided to patients. In contrast, the CfP are primarily financial, determining the conditions under which hospice providers will be reimbursed for their services.

Keys To Success

The interplay between the CoP and CfP presents several challenges for hospice providers. Regulatory compliance can be time-consuming and resource-intensive, diverting attention from direct patient care. Additionally, financial pressures can lead some organizations to prioritize documentation and billing over fulfilling all patient needs. Below are some best practices to ensure success in meeting both the CoP and the CfP:

• Verify— at the time of completion—that all of the required elements of election statement are present.
• Ensure that all of the required elements for the Plan of Care are present as well as signed and dated by the provider.
• Certification of terminal illness narratives should be written by the physician and never copied and pasted from nursing narratives. Only a physician can certify terminal illness.
• Conduct mock surveys routinely to check for readiness.
• Take advantage of technologies such as hospice software and other tools to ensure accuracy in workflows
• Conduct internal audits for documentation completeness and implement process improvements.
• Track and schedule face to face encounters.
• Create a process to ensure that hospice addendum statements are provided, when requested, in the allowed time frame.
• Train and onboard staff and providers so that they understand the CoP and CfP requirements.

Summary

While CoPs aim to protect patients and ensure they receive appropriate and compassionate care, CfPs focus on the financial viability of hospice agencies. This dual framework can create tension, as hospice providers must navigate the complexities of meeting both quality standards and documentation requirements to secure payment.

Noncompliance with CoPs can lead to loss of certification, while failure to meet CfPs can result in financial losses. Thus, hospice providers face the challenge of balancing high-quality patient care with the administrative demands of reimbursement. Ensuring accurate and complete documentation and building processes and workflows to ensure requirements are met is essential to participating in government payer programs and getting paid for the services provided to hospice patients.

Additional blogs:

1. Home care and hospice collaboration
2. Best financial practices for hospice care agencies
3. The keys to quality improvement in hospice agencies
4. Building strong partnerships with hospice stakeholders
5. What are the crucial skills for home health and hospice hiring?