Starting a hospice is a licensing project with a business attached, and the order matters more than the effort. Most people who stall do so because they built the company before they understood the state's certificate of need position or the Medicare certification survey. This page sets out the sequence an applicant actually has to work through, and the points where the money and the waiting are concentrated.
Start with your state, not your business plan
Before anything else, find out whether your state operates a certificate of need process for hospice, and if so whether it is currently accepting applications. In states that do, the answer decides whether this venture is possible at all this year. In states that do not, licensure is the first gate. Either way the state health department's rules, not a generic guide, are the specification you are building to.
Licensure, then Medicare certification, then accreditation
The usual order is a state licence to operate, then enrolment and a survey for Medicare certification, then accreditation if you choose or your state requires it. Each has its own paperwork, its own timetable and its own inspection, and each expects the one before it to be complete. Building the policy manual once, properly, and using the same document through all three is the difference between a nine-month process and a two-year one.
What the money goes on before the first admission
Payroll for a clinical team you must employ before you have patients, the interdisciplinary staffing the conditions of participation require, an EMR, insurance, and working capital to cover the gap between admission and payment. The last one is what closes new hospices: claims do not pay on the day of the visit, and a hospice business needs enough cash to run a full billing cycle with a small census before revenue arrives.
The survey is a documentation exam
A surveyor reads records. That means your policies, your patient charts, your interdisciplinary group minutes and your personnel files need to be complete and consistent from day one, not assembled the week before. Agencies that write the policy manual as an operational document, and use it, pass; agencies that buy a template and file it fail on the gap between what is written and what staff actually do.
Questions people ask about how to start a hospice business
How long does it take to open a hospice?
Commonly twelve to eighteen months from decision to Medicare certification in states without a certificate of need process, and considerably longer where one applies. The variable is rarely your speed; it is the state's queue and the survey schedule.
Can we admit patients before Medicare certification?
You can admit private-pay patients once licensed, and some new hospices do so to demonstrate operations at survey. You cannot bill Medicare for care delivered before your certification date, so treat that period as an investment rather than revenue.
Do we need a medical director from the start?
Yes. The conditions of participation require one, and the survey will look at their involvement in the interdisciplinary group rather than just their signature on a contract. Budget for a genuine clinical relationship, not a nominal appointment.
Is buying an existing hospice easier than starting one?
Often faster, because the licence and certification exist, but the diligence burden is real: you inherit the compliance history, the survey findings and any outstanding claims exposure. Both routes need the same understanding of the rules; only one lets you learn them after the fact.