Hospice providers in Georgia and Ohio should take note of an important regulatory development that may have far-reaching implications. While the immediate extensions is limited to expanding to these two states, this change has the potential to affect hospice providers nationwide in the future.
The PPEO program, or Provisional Period of Enhanced Oversight, is a medical review program designed to focus on new hospices, hospices that have undergone a change in ownership, or hospices whose provider number was deactivated for billing purposes and later reactivated. This can occur for reasons such as missing a cost report deadline, failing to self-report the hospice cap, or not completing required revalidation on a routine basis.
This provisional oversight under the PPEO program has already been in effect for some time in California, Arizona, Nevada, and Texas. It is now being expanded to include Georgia and Ohio for any providers that meet the eligibility criteria on or after December 30, 2025.
Under this process, patient charts are medically reviewed, and rapid determinations are made regarding the viability of a hospice. We have firsthand experience supporting clients who have acquired hospices in affected states, helping them navigate the PPEO review process successfully.
We have received calls from hospices after undergoing two levels of review. In one case, only five charts were reviewed in the first round and five in the second, with three of five denied in the first review and four of five denied in the second. As a result, the hospice was completely shut down and barred from reapplying to the Medicare program for ten years.
We have received calls from at least five hospices in the affected states where this has occurred. While the number of charts reviewed has varied, the reviews have involved very small samples, yet the hospices have been shut down. This is an extremely serious situation.
Medical review is serious under any circumstances, but the PPEO program, particularly for new providers, can prevent a hospice from ever fully launching before being shut down. It is critical to be extremely diligent with hospice documentation, to admit only patients who clearly meet eligibility requirements, and to be meticulous when responding to an ADR review. All documentation must be complete, accurate, and fully compliant in the first round of submission.
At any stage of medical review, if you receive a denial you believe is incorrect, it is critical to appeal it immediately. Deadlines cannot be missed. Providers are given the opportunity not only to appeal individual chart denials, but also to appeal a decision to terminate a provider number. These appeals must be filed in a timely manner and supported by complete and appropriate documentation to be effective.
An article outlining this information can be found via the Medicare Learning Network. Please note that it went into effect on December 30, so all of the states mentioned should remain especially vigilant if any of these situations apply within your organization, particularly for new providers or those undergoing a change in ownership.
On January 28, Tammy Stewart, Clinical Consultant will present our FREE webinar “Hospice: Back to the Basics & Key Concepts”. This webinar will provide you with practical insight into key concepts such as patient eligibility, levels of care and the vital role of the interdisciplinary team. To register for this webinar, click here.
Healthcare Provider Solutions is prepared to support you with any medical review challenges, whether in home health or hospice. If you need help, please do not hesitate to reach out to us.
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