By Melba Rebong Militante
CEO, Phoenix Virtual Solutions
With Firsthand Experience in Healthcare Operations and Compliance
I have never filed a late Notice of Election. In hospice, that is not a small claim, and I want to be clear that it is not luck either. Instead, it comes down to three habits. We treat the five-day window as a four-day window. We also track acceptance, not just submission. And we keep the person watching that clock separate from anyone carrying a clinical caseload. In short, a well-trained hospice admissions virtual assistant makes that discipline possible.
I have seen plenty of agencies who cannot say the same, and almost none of them were careless. For instance, the admission came in on a Friday afternoon with a same-day effective date. Then the certification sat in a fax queue. The NOE went out on day four and came back for correction on day six, and nobody was checking. Still, Medicare does not weigh the reason. As a result, the days between the effective date of election and the actual posting date are not billable. Medicare will not cover them, and you cannot bill the family either. Often, you do not find out until weeks later, on a remittance advice.
The Real Risk Sits in the Administrative Sequence
That is the part of hospice admissions most agency owners underestimate. The clinical decision — is this patient appropriate for hospice — gets most of the attention. It genuinely requires physician judgment. But the revenue risk and the survey exposure sit somewhere else entirely. Specifically, they sit in the administrative sequence around that decision. A hospice admissions virtual assistant assembles the compliant election statement. Next, she routes the certification of terminal illness through two physicians. Then she gets the NOE filed and accepted within five calendar days.
That sequence is administrative work. In fact, it is exactly the work a trained hospice admissions virtual assistant is built to carry. This post walks the sequence step by step. First, it shows where a VA takes the load. Just as importantly, it also draws a hard line around where the VA’s work stops and your clinical team’s begins. Want the full picture of every VA role across your agency? Start with our complete guide to home health and hospice virtual assistant roles.
The Admissions Sequence: What Your Hospice Admissions Virtual Assistant Must Get Right, In Order
A Medicare hospice admission is not a single event. Instead, it is four dependent steps, each with its own document, its own signer, and its own clock. Miss the order, and you create rework. Likewise, miss a clock, and you create a non-covered period.
The Hospice Admissions Sequence |
1. Referral intake and eligibility groundwork — insurance verification, benefit period history, prior elections, and coordination-of-benefits issues found before the visit. |
2. Election statement — signed by the patient or the patient’s representative, establishing the effective date of election. |
3. Certification of terminal illness (CTI) — obtained from two physicians for the initial period. Includes a physician-composed narrative for a six-month-or-less prognosis. |
4. Notice of Election (NOE) — filed with your Medicare contractor within 5 calendar days of the effective date and confirmed as accepted afterward. |
Steps 2, 3, and 4 are where agencies bleed. Not because the rules are obscure. Instead, it is because the people who understand them are the same people carrying a clinical caseload.
Step 1: The Election Statement — Where the Clock Actually Starts
Under 42 CFR 418.24, a Medicare beneficiary elects hospice by filing an election statement with a particular hospice. That statement is not a formality. Rather, it sets the effective date of election. From there, you measure every subsequent deadline.
The regulation lists eight required contents. First, the statement identifies the particular hospice and the patient’s attending physician. The patient or representative must acknowledge that the physician was their own choice. Second, it records that the patient understands hospice care is palliative, not curative. Third, it acknowledges that the patient received information on the hospice’s coverage responsibility. It also notes that the election waives certain Medicare services. Fourth, it states the effective date of the election. That date, in turn, cannot come before the date of the statement itself.
For elections beginning on or after October 1, 2020, four more elements apply. First, the statement must include individual cost-sharing information. Second, it must notify the patient of the right to an election statement addendum. This applies where the hospice has flagged conditions, items, services, or drugs as unrelated to the terminal illness. Third, it must also include information on the Beneficiary and Family Centered Care Quality Improvement Organization. That includes the right to immediate advocacy and BFCC-QIO contact information. Finally, the eighth element is the signature of the patient or representative.
A patient, representative, non-hospice provider, or Medicare contractor can request that addendum. The furnishing deadline then depends on when the request comes in. Requested within the first five days of the election, the hospice has five days from the date of the request. Requested later in the course of care, however, the hospice has three days. That is a second clock running alongside the NOE clock. Yet it is the one that agencies most often fail to track.
What the Hospice Admissions Virtual Assistant Handles
The VA does not obtain consent. The VA also does not explain the palliative-versus-curative election. Instead, that conversation belongs to your admitting clinician. The VA prepares the packet so missing paperwork never delays that conversation. Afterward, she verifies that everything came back complete and correctly dated.
Election Statement Support Tasks |
Preparing the election statement packet from your agency’s current approved template |
Confirming the designated attending physician is recorded and spelled correctly against NPI records. |
Reviewing the returned statement for signature, date, and completeness before it is filed to the chart |
Flagging any statement where the effective date is unclear or inconsistent with the admission visit date |
Logging the effective date of election as the trigger for the NOE and certification clocks |
Tracking any addendum request against its furnishing deadline. Five days if requested in the first five days of the election; three days if requested later. |
Escalating a missing or defective element to the admissions nurse or administrator the same day |
In fact, the effective date of election is the single most consequential field in the entire admission packet. You measure every deadline that follows from it. Yet someone still enters it by hand.
Step 2: Certification of Terminal Illness — Two Physicians, One Narrative
For the initial 90-day benefit period, certification of terminal illness requires two physicians. One is the hospice medical director or a physician member of the interdisciplinary group. The other is the patient’s attending physician, if the patient has designated one. After that, subsequent benefit periods require only the hospice physician. In addition, a brief narrative must support the certification. That narrative must explain the clinical findings behind a life expectancy of six months or less. The certifying physician must write it — not staff, and not as a draft passed along for signature.
That last point is where agencies get into trouble, and it is the clearest illustration of the administrative boundary. For example, a VA can track whether the narrative is present. However, a VA cannot write it, summarize the clinical findings into it, or suggest language for it.
The practical failure mode here is rarely refusal. It is delay. For example, the attending physician is in clinic. The fax sits in a queue. The office manager is out. The signature arrives eleven days later. Meanwhile, written certification must be in the record before you can bill. If you accepted a verbal certification instead, you are now tracking a second deadline on top of the first.
What the Hospice Admissions Virtual Assistant Handles
Certification of Terminal Illness Support Tasks |
Identifying both required certifying physicians at admission and confirming current contact and fax routing for each |
Transmitting the certification request and logging the date and time of each transmission |
Running structured follow-up on unsigned certifications on your agency’s defined cadence |
Confirming a physician-composed narrative is present in the returned document; presence only, never content. |
Tracking verbal certifications against the deadline for written follow-up |
Escalating any certification approaching your internal threshold to the hospice medical director or administrator |
Filing the completed certification to the correct benefit period in the EMR |
Step 3: The Notice of Election and the 5-Day Clock
Under 42 CFR 418.24(e), the hospice must file the Notice of Election with its Medicare contractor. This filing is due within 5 calendar days after the effective date of the election statement. In other words, calendar days, not business days — a Friday effective date does not buy you the weekend.
When the NOE is not filed on time, Medicare will not cover the days of hospice care. Specifically, this gap runs from the effective date of election to the date you file the notice. The regulation is explicit: those days are a provider liability. The provider may not bill the beneficiary for them. As a result, you absorb them.
The Narrow CMS Waiver Exception
CMS may waive that consequence, but only for circumstances it determines were beyond the hospice’s control. The regulation names four situations. First, fires, floods, earthquakes, or similar events that damage the hospice’s ability to operate. Second, a CMS or Medicare contractor systems issue outside the hospice’s control. Third, a newly Medicare-certified hospice notified of certification after the certification date, or still awaiting its contractor user ID. Fourth, other situations CMS determines to be beyond the hospice’s control. Even so, read that list honestly. None of it covers a signature that sat in a fax queue.
There is a second failure mode that catches agencies who believe they are compliant. A submitted NOE is not an accepted NOE. If the NOE returns to the provider for correction, the clock does not stop while you fix it. For example, picture an agency that files on day four but never checks the status. If a return shows up on day nine, that agency has a five-day non-covered period it never saw coming.
Filing the NOE is a task. However, confirming the NOE was accepted is the job. As a result, agencies that only track the first one are exposed and do not know it.
What the Hospice Admissions Virtual Assistant Handles
Notice of Election Filing Support Tasks |
Maintaining a live NOE tracker keyed to the effective date of the election, with days remaining visible at a glance. |
Preparing and submitting the NOE through your MAC portal on your agency’s defined internal deadline, ahead of day five |
Checking submission status daily until acceptance is confirmed, not just until submission is complete |
Logging the acceptance timestamp to the patient record as audit evidence |
Escalating any returned-to-provider NOE immediately, the same day it appears. |
Producing a monthly NOE timeliness log for administrator and Client Success Manager review |
Eligibility and authorization questions frequently surface during this same window. Notably, this is particularly true for patients with Medicare Advantage coverage or concurrent care arrangements. Our post on prior authorization for hospice care covers that side of the intake conversation in more detail.
Where the Hospice Admissions Virtual Assistant's Work Stops: The Administrative Boundary
I want to be direct about this. In fact, it is the question every hospice administrator should ask any staffing company. And the honest answer is narrower than what some vendors will tell you.
A Phoenix hospice admissions virtual assistant performs administrative and coordination work only. Specifically, the VA assembles, transmits, tracks, logs, confirms receipt, and escalates. The VA does not determine hospice eligibility. Likewise, she does not assess or interpret clinical findings. She does not compose or edit the physician narrative. She does not conduct the election conversation with the patient or family. And she does not make any decision that depends on clinical judgment.
The Line, Stated Plainly |
VA: tracks whether the certification narrative is present. Clinical team: writes it. |
VA: prepares and routes the election statement packet. Clinical team: conducts the election conversation. |
VA: flags a patient approaching a benefit period transition. Clinical team: determines continued eligibility. |
VA: files the NOE and confirms acceptance. Administrator: owns the compliance outcome. |
VA: escalates anything ambiguous, the same day, per protocol. Your team: decides. |
Many Phoenix VAs hold RN credentials from their home country. That background makes them faster and more reliable at recognizing when something in a packet looks wrong. They know when it needs to go up the chain. Even so, it does not move the boundary. An RN-credentialed VA working an administrative role is still working an administrative role. Therefore, we deliberately train and supervise to that standard.
Why This Works: Your Hospice Admissions Virtual Assistant Is an Extension of Your Team, Not a Vendor Down the Hall
A hospice admissions virtual assistant is only useful inside your systems. In other words, she needs your workflow, your EMR, your templates, and your escalation chain. Phoenix places VAs as an extension of your on-staff team for exactly that reason. Your VA works your admission checklist, uses your election statement template, and follows your escalation thresholds. She reports to your admissions supervisor. Instead, she is not running a parallel process and handing you output.
Above that sits the second layer: your dedicated Client Success Manager, who functions as an extension of your management oversight. For a hospice client, your CSM tracks the metrics that tell you whether admissions is actually healthy. Specifically, these include the NOE timeliness rate, average days from effective date to accepted NOE, and certification turnaround by physician. They also include the count of returned-to-provider NOEs. When a number drifts, the CSM raises it with you early. That happens before it shows up as a non-covered period on a remittance advice.
That oversight layer is the difference between placing a person and building a function. In contrast, placement alone drifts. It always does.
What Comes After Admission
Admission is the front half of the hospice administrative cycle. In turn, the back half is the recurring cadence. It includes the interdisciplinary group meeting every 15 calendar days and the benefit period transitions. It also includes the face-to-face encounter requirement that begins before the third benefit period. That cycle is its own workflow, with its own failure modes. We cover it in the next guide in this series.
Frequently Asked Questions
What is a hospice admissions virtual assistant?
A hospice admissions virtual assistant is a remote administrative professional trained specifically in the Medicare hospice admission workflow. Specifically, the VA prepares the election statement packet. She coordinates and tracks the certification of terminal illness through both required physicians. Then she files the Notice of Election with your Medicare Administrative Contractor, confirms acceptance, and escalates anything that stalls. The VA works inside your EMR, follows your agency’s documented procedures, and reports to your internal admissions supervisor.
How long do I have to file a Notice of Election?
Under 42 CFR 418.24(e), the hospice must file the NOE with its Medicare contractor. This is due within 5 calendar days after the effective date of the election statement. Calendar days include weekends and holidays. If the NOE is late, Medicare will not cover those days. The gap runs from the effective date of election to the date of filing. As a result, those days are a provider liability, and you cannot bill the beneficiary for them.
How many elements does the hospice election statement have to contain?
Eight, under 42 CFR 418.24(b). Specifically, these include identification of the hospice and the attending physician, with acknowledgment that the physician was the patient’s choice. In addition, they include acknowledgment of the palliative, not curative, nature of hospice care. Also, they include acknowledgment of the hospice’s coverage responsibility and the Medicare services the election waives. They include the effective date, individual cost-sharing information, and notification of the right to an election statement addendum. They include BFCC-QIO information, including the right to immediate advocacy, and the signature of the patient or representative. The final four apply to elections beginning on or after October 1, 2020.
Does a virtual assistant decide whether a patient is eligible for hospice?
No. Eligibility is a clinical determination made by physicians. Instead, the VA supports the administrative sequence around that determination, i.e., assembling documents, routing signature requests, tracking deadlines, and escalating gaps. Specifically, the VA does not assess patients, interpret clinical findings, or make any eligibility judgment.
How many physicians must certify terminal illness?
For the initial benefit period, two physicians must certify. One is the hospice medical director or a physician member of the interdisciplinary group. The other is the patient’s attending physician, if one has been designated. After that, subsequent benefit periods require certification from the hospice physician only.
Can a virtual assistant write the physician narrative for the certification?
No. The certifying physician must write the narrative explaining the clinical findings that support a six-month prognosis. Instead, Phoenix VA confirms the narrative is present in the returned document and escalates if it is missing. The VA never drafts, edits, or suggests language for it.
What happens if the NOE is returned to provider for correction?
The clock does not stop. The five-day window runs from the effective date of election, regardless of whether a submitted NOE is later returned. This is why confirming acceptance matters as much as filing. Consequently, a Phoenix hospice admissions virtual assistant checks submission status daily until acceptance is confirmed. She escalates any return the same day it appears.
Do Phoenix hospice VAs work in our EMR?
Yes. Phoenix hospice VAs work in WellSky Hospice, Homecare Homebase, MatrixCare, and Hospicelink. The VA trains on your platform before placement. In addition, onboarding includes a review of your election statement template, your certification routing, and your internal NOE deadline.
How does Phoenix make sure admissions performance does not slip over time?
Every Phoenix client has a dedicated Client Success Manager who functions as an extension of your management oversight. For hospice clients, the CSM tracks NOE timeliness, average days to accepted NOE, certification turnaround by physician, and returned-to-provider volume. She raises drift with you before it affects revenue.
Where to Start
If your admissions process depends on one person remembering which NOE is due, you do not have a process. You have a single point of failure. Start by pulling your last ninety days of NOE filings. Measure the gap between the effective date of the election and the accepted filing date. That number tells you whether this is a staffing problem or a workflow problem. Want the full breakdown of every administrative role a hospice admissions virtual assistant fills across home health and hospice? See our complete guide to home health and hospice virtual assistant roles. To see how Phoenix structures this support, visit our home health and hospice service page.
Regulatory References
- 42 CFR 418.24: Election of Hospice Care. View source
- 42 CFR 418.24(b): Content of election statement — the eight required elements. View source
- 42 CFR 418.24(d) and (e): Addendum timeframes; Notice of Election, consequences of late filing, and exceptions. View source
- 42 CFR 418.22: Certification of Terminal Illness. View source
- 42 CFR Part 418: Hospice Care (full part). View source
- CMS Hospice Services Provider Compliance Tips. View source
About the Author
Melba Rebong Militante is the CEO of Phoenix Virtual Solutions, a healthcare-focused virtual staffing agency serving home health, hospice, and medical practices across the United States.
She brings years of healthcare leadership experience across multiple large health systems, a background in IT Project Management Consulting, and firsthand experience managing offshore staffing relationships as a US hospital client. She also owns and operates a hospice agency, giving her direct insight into compliance, workforce operations, patient intake, and revenue cycle management.
That combined experience shapes how Phoenix trains, places, and supports every virtual medical assistant.
