In early April 2026, the National Alliance for Care at Home publicly urged CMS to rethink its proposed Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) rule, arguing that existing tools—chief among them the Provisional Period of Enhanced Oversight (PPEO)—already give CMS what it needs to root out hospice fraud without burdening legitimate providers.

For hospice operators already navigating PPEO in Arizona, California, Nevada, Texas, Georgia, and Ohio, the Alliance's comments are a strong signal: PPEO isn't going away. If anything, CMS is being told to double down on it.

What Is CRUSH?

CRUSH is a CMS proposed rule aimed at fraud, waste, and abuse across Medicare and Medicaid. Among other things, it targets:

  • Solicitation of beneficiary personally identifiable information
  • Fraudulent claims tied to international operators
  • Weak identity verification during provider enrollment

The intent is good. The Alliance's concern is that CRUSH, as written, is broad enough to sweep in compliant providers while doing little to stop sophisticated bad actors.

The Alliance's Recommendation: Target, Don't Blanket

Hillary Loeffler, the Alliance's vice president of policy, summarized the position bluntly: “CMS doesn't need to put a whole bunch of regulations in place” but instead should “better target their efforts to those committing fraud.”

Specifically, the Alliance is asking CMS to adopt a risk-based approach that emphasizes:

  • Forensic accounting to flag suspicious billing patterns inside state records
  • Risk-tiered investigations so resources go to the highest-risk providers first
  • Beneficiary ID tracking to detect repeat billing fraud across providers
  • Regional focus on known fraud hotspots (California in particular) instead of sweeping statewide rules
  • Consistent training across Medicare Administrative Contractors
  • Public appeals data for transparency on how denials are holding up

Critically, the Alliance singled out PPEO as one of the existing tools CMS should be using more aggressively—not replacing.

Why This Matters for Hospices

If CMS takes the Alliance's advice, the practical effect is straightforward: PPEO becomes the primary enforcement vehicle for new and changing-ownership hospices, and the bar for surviving it doesn't get any lower.

Recall the numbers from the December 2025 PPEO update: of 817 hospices reviewed, 181 lost their Medicare enrollment—a 22% revocation rate. That number is the backdrop to every policy conversation happening right now in Washington. Both CMS and industry groups view PPEO as effective. The disagreement is over whether additional regulations like CRUSH are needed on top of it.

For hospice owners and administrators, the takeaway is the same regardless of how the CRUSH rulemaking shakes out:

  • If you're newly enrolling, reactivating, or going through a change of ownership in a PPEO state, expect intensive review
  • Documentation of eligibility, certification, and face-to-face encounters needs to be airtight before claims go out the door
  • ADR responses need to be complete, on time, and strategically organized
  • Appeals on denied claims should be the rule, not the exception

Watch the Hotspots

The Alliance specifically called out California as a region warranting concentrated enforcement. That language matters. It suggests CMS may continue to layer additional scrutiny on top of PPEO in the markets where fraud reports have grown fastest—and that hospices operating in or expanding into those markets should plan accordingly.

Georgia and Ohio, added to PPEO at the end of 2025, are the most recent additions. There's no indication CMS plans to stop there. Any state showing rapid hospice enrollment growth combined with elevated fraud reporting is a candidate.

What to Do Now

Whether CRUSH moves forward in its current form, gets revised, or is replaced by sharper PPEO enforcement, the operational answer for hospices is the same: be ready to be reviewed.

  • Audit your documentation against the criteria PPEO reviewers actually use
  • Tighten certification and recertification workflows so nothing slips between visits
  • Train your clinical and billing staff on what an ADR response should look like
  • Know your medical director's outside affiliations—CMS does
  • Have an appeals plan ready before the first denial arrives

PPEO Consulting: $300/hour

Whether CMS sticks with PPEO, expands it, or layers CRUSH on top, the documentation expectations aren't going anywhere. We help hospices prepare before the ADRs start arriving.

Schedule a Consultation

Further Reading

The Bottom Line

The policy debate in Washington is shifting toward “use the tools you already have, better.” PPEO is the tool. For hospices in affected states, that means the standard isn't going to relax—and the cost of being unprepared is still your Medicare enrollment.