Hospice Council Members,
CMS has extended the Provisional Period of Enhanced Oversight (PPEO) and the expanded prepayment review of existing hospices to Georgia and Ohio.
The PPEO is for new hospices only with new hospices defined as:
● Newly enrolling in the Medicare Program
● Submitting a change of ownership that meets all the regulatory requirements under 42 CFR 489.18
● Undergoing a 100% ownership change that doesn't fall under 42 CFR 489.18
● Reactivating after being in a deactivated status
PPEO includes medical review of hospice claims, such as prepayment review. PPEO was started for new hospices in California, Arizona, Nevada and Texas in July 2023 and is still continuing in those states. Hospices in Georgia and Ohio meeting the definition of a new hospice on or after 12/30/2025 will be subject to PPEO which can last up to one year or as little as 30 days. CMS determines the timeframe for each hospice and will notify hospices via a mailed letter to the correspondence address in the hospice's PECOS file.
Experiences of hospices in states that have been subject to PPEO previously is that there are few claims selected for review, usually ten or less. The hospices must meet the acceptable error rate used by their respective Medicare Administrative Contractor (MAC). This error rate is set by the MAC. Currently, each MAC is using the same acceptable error rate for PPEO that it does for its Targeted Probe & Educate (TPE) medical review. Considering the low number of records that are part of the PPEO medical review, there is not much room for error. It is important to note that PPEO is not the same process as a TPE review. Under PPEO a lower number of claims is pulled and there do not have to be "rounds" of review. For example, a new hospice may have ten records reviewed with CMS taking final action after the review. The Alliance has heard from some new hospices in California, Texas, Arizona and Nevada that they have had more claims pulled for review after the initial record request and they have had the opportunity for education. However, the opportunity to receive education and/or to have additional records reviewed is not required under PPEO. Actions that CMS can take after review under PPEO include but are not limited to termination from the Medicare program, termination with a re-enrollment bar, and extended prepayment review.
The expanded prepayment review of existing hospices is similar to PPEO, but is for all existing hospices in these states. Similarities include the low number of records reviewed, application of the same acceptable error rate, no need for additional records to be reviewed or education to be offered. Hospices in the four states where expanded prepayment review has been occurring since it was implemented in September 2024 report that CMS often implements 100% prepayment review for hospices that did not meet the acceptable error rate. However, actions can and have included termination and re-enrollment bars.
CMS posted an MLN Fact Sheet for the extension of PPEO to Georgia and Ohio and also posted an MLN Fact Sheet for the expanded prepayment review of existing hospices in these states. The PPEO Fact Sheet indicates that hospices meeting the definition of a new hospice on or after July 13, 2023 are subject to the PPEO; however, the Alliance understands that this is an error and the date should be December 30, 2025.
The Alliance is watching the activities under these expansions closely and will provide updated information as it becomes available.
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Katie Wehri
Vice President of Regulatory Affairs, Quality & Compliance
National Alliance for Care at Home
Washington DC
+1 (202) 547-7424
kwehri@allianceforcareathome.org------------------------------