Hospice providers in Georgia and Ohio should take proactive steps now to minimize operational disruption and denial risk from new scrutiny ordered in December 2025 by the Centers for Medicare & Medicaid Services.
CMS added providers in Georgia and Ohio to its Provisional Period of Enhanced Oversight (PPEO) and Expanded Prepayment Review (EPR) programs (effectively, prepayment medical review for claims). Hospice providers in Arizona, California, Nevada and Texas already are subject to these oversight measures.
According to CMS, these actions reflect an ongoing commitment to program integrity in the hospice sector. As of June 2025, CMS reported that 668 hospice providers were subject to a PPEO, and CMS revoked the Medicare enrollment for 122 of these hospices.
What Are PPEO and EPR Programs?
The PPEO and EPR programs are oversight tools that CMS uses to increase scrutiny of claims and provider operations during a provisional period. Under these measures, affected hospice providers may have claims held for medical review before payment. Elevated error rates can lead to corrective actions up to and including revocation of Medicare billing privileges. In more serious cases, CMS may terminate a hospice’s Medicare enrollment entirely.
What Triggers a PPEO or EPR?
CMS and its Medicare Administrative Contractors (MACs) deploy two related tools in targeted states: PPEO for newly enrolled or newly controlled hospices and EPR for existing hospices based on risk. Criteria and duration can vary by MAC and CMS directive, but there are common triggers.
| Trigger | What Happens |
|---|---|
| New Enrollment | Hospices initially enrolling in Medicare in the targeted states are typically placed into PPEO. Early claims are subject to prepayment medical review before routine payment resumes. |
| Change of Ownership | Ownership changes that meet the criteria under 42 C.F.R. § 489.18 — or certain 100% ownership changes outside that regulation — can result in the hospice being treated as “newly enrolled” for oversight purposes and placed into PPEO. |
| Material Enrollment Changes | Significant enrollment events (e.g., reactivation after deactivation) may prompt MAC risk-based scrutiny. Depending on risk, a hospice could be placed into PPEO or selected for EPR. |
For more details on triggers, see the CMS guidance document on enhanced oversight for hospices.
What Does This Mean for Georgia and Ohio Hospice Providers?
Under prepayment review, the MAC will suspend selected claims and issue additional documentation requests (ADRs) to determine whether the claims support the services billed and are eligible for payment. The MAC will withhold payment until the hospice timely responds to the ADR, and the MAC determines that the claim is payable. Oversight periods may last between 30 days to a year, and a MAC’s medical review authority can continue even after a PPEO ends. In practice, hospices should anticipate:
- More frequent and time‑sensitive ADR requests tied to specific claims.
- Delays in payment determinations and potential cash‑flow disruption.
- Increased denial risk for incomplete, late or nonresponsive submissions.
- Greater emphasis on clinical substantiation of terminal illness and related conditions, levels of care and relatedness determinations.
- Potential revocation of Medicare billing privileges if error rates exceed certain percentages (especially if denials stem from clinical eligibility).
Providers retain appeal rights for claim denials and revocation of billing privileges, but appeals ultimately extend the timeline to resolution and payment, assuming appeals are successful.
What Steps Should Hospice Providers Take Now?
Hospice providers in Georgia and Ohio should review their current compliance programs and billing practices immediately to ensure readiness for PPEO and EPR enforcement. Hospice leadership and stakeholders can take steps to mitigate denial exposure and cash‑flow impact now.
- Monitor Ownership Changes and Enrollment Updates. These events are often triggers for PPEO and EPR. Recent CMS enrollment safeguards may also limit conveyance of Medicare billing privileges in certain change of ownership scenarios. See McGuireWoods’ prior alert on the “36-month rule” for more information.
- Strengthen Certification Workflows. Strengthen certification and recertification workflows, including pre‑billing checks for narrative adequacy, signature/date verification and timely completion relative to benefit period boundaries.
- Build a Centralized ADR Response Process. Establish a centralized intake, tracking and quality-control process for ADRs with clear ownership, checklists aligned to review topics and escalation paths. Nonresponse results in automatic denials and can affect enrollment standing.
- Conduct Targeted Documentation Audits. Conduct targeted documentation audits focused on eligibility narratives, face‑to‑face encounter compliance and higher‑acuity levels of care. Triage claims that are more likely to be selected for review.
- Standardize Interdisciplinary Group (IDG) Documentation. Standardize IDG documentation and care plan updates to reflect objective indicators of decline, symptom burden and treatment responses. Make sure visit frequencies align with clinical need and the plan of care.
- Review Relatedness Determinations. Review relatedness determinations for drugs, durable medical equipment, and services and ensure rationales are documented and consistent with CMS policy and MAC guidance.
- Model Cash-Flow Scenarios. Model cash‑flow scenarios that reflect longer payment cycles for reviewed claims and consider reserving for potential denials pending appeal.
- Engage Counsel Early. In the event of PPEO placement or EPR review, involve legal counsel early to support ADR strategy, privilege-protect sensitive analyses and prepare for appeals as needed.
McGuireWoods continuously monitors CMS developments affecting hospices and related stakeholders. For more information, contact one of the authors or a member of the Healthcare Compliance, Regulatory & Policy Practice Group.