CMS Expands Enhanced Oversight to Hospice Providers in Georgia and Ohio
Hospice providers in Georgia and Ohio are being encouraged to get ready to face increased federal scrutiny due to new enforcement measures announced by the Centers for Medicare and Medicaid Services (CMS).
In December 2025, both states were included in the Provisional Period of Enhanced Oversight (PPEO) and Expanded Prepayment Review (EPR) programs, which subject claims to medical review before payment. The action will expand the control on hospice providers in Arizona, California, Nevada, and Texas.
According to CMS data released in June 2025, 668 hospice providers nationwide were subject to PPEO, and 122 had their Medicare enrollment revoked as a result of oversight findings.
PPEO and EPR Programs
PPEO and EPR are administrative measures that aim at paying close attention to hospice providers deemed to pose a high level of compliance or fraud risk. Medicare Administrative Contractors (MACs) under such programs can hold claims for medical review before payment. This implies that further documentation must be provided before claims can be approved for reimbursement.
Where providers have shown high rates of error relating to clinical eligibility, CMS can take corrective measures, revoke billing rights, or suspend Medicare enrollment.
What Triggers Enhanced Oversight?
PPEO or EPR is implemented by CMS and its MACs on the basis of certain risk indicators, as stated in the table. The scope and duration of oversight vary by MAC and CMS directive.
| 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. |
Check out the CMS guidance document on enhanced oversight for hospices.
Impact on Georgia and Ohio Providers
Under prepayment review, selected claims are suspended while MACs issue Additional Documentation Requests (ADRs) to verify medical necessity and billing accuracy.
Providers should expect:
- Increased volume of time-sensitive ADRs.
- Late payments and possible cash-flow problems.
- Increased risk of denial of incomplete or delayed submissions.
- More intense scrutiny of terminal illness certification, levels of care, and relatedness determinations.
- If error rates surpass specific percentages, Medicare billing privileges may be revoked.
The period of oversight can be from 30 days to one year, and the medical review authority of CMS can be extended even when a PPEO formally ends. Although the providers have the right to appeal, the appeal process can greatly delay payment schedules.
Steps Hospice Providers Should Take
According to industry experts, hospice providers in Georgia and Ohio need to take the initiative to minimize compliance risk. Some of the preparatory measures are:
- Monitor ownership and enrollment changes closely
- Strengthening certification and recertification workflows
- Centralization of the ADR response mechanism
- Conduct target documentation audits
- Standardize Interdisciplinary Group (IDG) Documentation.
- Review relatedness determinations for drugs, durable medical equipment, and services.
- Model cash flow scenarios for long payment cycles.
- Engage legal counsel early if placed under enhanced oversight.
