New hospices in four states are currently under enhanced oversight, as part of the Provisional Period of Enhanced Oversight (PPEO) initiated by the Centers for Medicare and Medicaid Services (CMS). This oversight impacts Medicare claims, subjecting them to prepayment and medical review. J’non Griffin, Senior Vice President of Coding and Compliance for SimiTree, provides insights into this development.
New hospices in four states in the Provisional Period of Enhanced Oversight program
The provisional period of enhanced oversight, or PPEO, applies to newly enrolled hospices in Arizona, California, Texas, and Nevada, according to J’non Griffin, Senior Vice President of Coding and Compliance for SimiTree.
“CMS has been ramping up hospice scrutiny overall, and one of its areas of focus is new hospices – those who got final approval for Medicare enrollment on or after July 13, 2023,” Griffin said.
Impact on Hospices in Targeted States: Effect on Hospice Compliance - Changes and Considerations
If a hospice in any of the four targeted states began the enrollment or certification process before July 13, 2023, but has not yet received the final approval letter, it may still be affected, Griffin said. Additionally, a change of ownership on or after July 13, 2023, could place some hospices in the PPEO.
Griffin said CMS may conduct medical reviews prior to payment on any claims submitted by affected hospices. The period of enhanced oversight can be as short as 30 days or as long as one year – and CMS can continue to conduct medical review after the provisional period of enhanced oversight has ended.
Notification and Response Ensuring Hospice Compliance: Notification and Response to PPEO
Hospices under the PPEO will receive notifications via email and under the documents tab in their CMS approval/change letters. Griffin emphasizes the importance of responding promptly to avoid claims denials or Medicare enrollment revocation.
“It’s important to respond,” she said. “Lack of response can result in claims denials or revocation of Medicare enrollment.”
Why CMS Initiated Enhanced Hospice Oversight
Factors Leading to Enhanced Hospice Oversight - Understanding CMS’s Perspective
There are two reasons for the enhanced oversight hospices in Arizona, California, Nevada, and Texas are facing, according to Griffin.
“First, the number of enrolled hospices has increased significantly in these four states, which always raises red flags for CMS and introduces serious concerns about market oversaturation,” she said.
A second and more concerning reason, Griffin said, is that last summer CMS reported that a significant number of addresses listed for newly enrolled hospices in the four targeted states appeared to be non-operational.
“One of the schemes associated with a fraudulent hospice operation by the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services is called a ’churn and burn’,” Griffin said. “In this kind of scheme, a new hospice opens and starts billing – but once that hospice is audited or reaches its statutory yearly payment limit, it shuts down and keeps the money. Then it just buys a new Medicare billing number so it can transfer patients over to the new number and start billing again.”
Schemes like the “churn and burn” are frustrating because they add significantly to the administrative burden for honest hospice organizations, leading to the additional paperwork handling necessary to fulfill prepayment review requirements, she said.
Broader Hospice Scrutiny Comprehensive Hospice Scrutiny: Trends and Programs
The hospice PPEO in Arizona, California, Nevada, and Texas is part of much larger overall scrutiny on hospice in recent years, resulting in the implementation of new survey and enforcement requirements, comprehensive training and testing for surveyors from accrediting organizations, and standardization of collection and public reporting of survey deficiency information.
In addition, CMS has begun a new pilot program scrutinizing hospice length-of-stay. The program focuses on the first 90 days of care among providers across all states.
“This increased attention on hospices has prompted many organizations to realize that it’s definitely time to make certain all aspects of their operation -- billing practices, coding, care planning, care coordination, and clinical documentation—are fully compliant,” Griffin said. “We’re working with many organizations now to help them put into place the policies, procedures and full risk mitigation plans needed to shore up compliance.”
Emphasizing Compliance Measures
Navigating Compliance in the Changing Landscape of Hospice Oversight
The OIG’s release of comprehensive new compliance guidance in late 2023 for all healthcare providers, including hospice, has further underscored the need for compliance, Griffin said.
“All types of healthcare providers, including hospices, need to have in place the basic elements of compliance set out by the OIG, and take a thorough look at their overall operation to make sure they are insulated against increasing scrutiny,” she said.
How SimiTree Can Help: Comprehensive Support for Hospices Facing Enhanced Oversight
If your hospice organization is targeted for a prepayment review under the PPEO, SimiTree can help. Our compliance team is made up of former auditors and surveyors with experience across healthcare settings and extensive expertise in Medicare methodology and the medical review process. Team members are both ACHC and CHAPS certified.
We help providers with all types of third-party audits by government contractors and commercial insurance, as well as investigations and reviews. We help with all ADRs, audits, and appeals – and we make short work of backlogs for prepayment reviews due to PPEO, the Review Choice Demonstration, or any other extra administrative requirements facing all types of providers.
From pre-bill audits to required HIPAA privacy assessments, full mock surveys, and the creation of individualized risk management plans, our compliance experts identify risks and work with organizations to ensure accurate billing practices with supporting clinical documentation for timely payment.
Use the form below to reach out to us today, and let’s tackle your compliance problem.