CMS has extended its Provisional Period of Enhanced Oversight (PPEO) and its Expanded Prepayment Review (EPR) enforcement efforts to Georgia and Ohio. The enhanced enforcement efforts can lead to the revocation of a hospice’s Medicare billing privileges, termination of Medicare/Medicaid enrollment, and/or the prepayment review of 100% of a hospice’s claims.
A very brief description of the PPEO/EPR processes is shown below. If you receive a notice from your MAC that you are being placed on PPEO or EPR—or if you begin to receive ADRs without explanation – please contact us immediately so that we can help you through these matters. It is crucial to respond to ADRs strategically and appeal any denials, as claim denials in PPEO can result in drastic consequences for hospices, as described below.
VERY Brief PPEO/EPR Overview: CMS’s process relating to these efforts is quite inconsistent, but generally. . .
PPEO
The target for the PPEO program is “new hospices,” which CMS defines as:
- Those newly enrolled 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 does not fall under 42 CFR 489.18
- Reactivating after being in a deactivated status
The PPEO program typically involves ADRs of a limited number of claims (e.g., one or two rounds of 10 claims). If the error rate exceeds 20% (particularly if the denials are for clinical eligibility), then CMS will often revoke that provider’s Medicare billing privileges.
EPR
The EPR may begin with a review of a limited number of claims. If the error rate exceeds 20% (again focusing on clinical denials), CMS will order the MAC to initiate a 100% prepayment review of all claims (effectively delaying or eliminating a significant amount of cash flow).
Our hospice team has been working with several clients in four western states (AZ, CA, NV, TX) where PPEO/EPR have been active for the past couple of years. Through that work, which involved direct outreach to the leaders at the CMS Provider Enrollment and Oversight Group (PEOG), we have developed strategies to prepare for, respond to, and appeal adverse results relating to these enhanced enforcement efforts. Our advocacy has been successful in avoiding or reversing the consequences that can result from a PPEO/EPR. We have also counseled hospices regarding merger and acquisition strategies relating to mitigating PPEO/EPR risk. If you would like to discuss these programs and our insights in greater detail, please contact Bryan Nowicki or another member of our Hospice Team.