At the end of December 2025, CMS expanded its Provisional Period of Enhanced Oversight (PPEO) to include Georgia and Ohio. Through December 2025, 817 hospices have already been subject to medical review under PPEO—and 181 of them had their Medicare enrollment revoked. If your hospice is newly enrolling, reactivating, or undergoing a change of ownership in these states, you need to understand what PPEO means for your business.

The stakes couldn't be higher. Failing PPEO can result in termination from the Medicare program, revocation of billing privileges, and even a re-enrollment bar that prevents you from participating in Medicare for years. Here's what you need to know.

What Is PPEO?

PPEO stands for Provisional Period of Enhanced Oversight. It's a CMS enforcement initiative designed to identify and address hospice fraud, waste, and abuse before problematic providers become established in the Medicare program.

During PPEO, CMS and its Medicare Administrative Contractors (MACs) conduct heightened scrutiny of hospice claims and documentation. This isn't a routine survey—it's an intensive review period where CMS is actively looking for reasons to deny claims or revoke your Medicare enrollment.

A PPEO can last anywhere from 30 days to one full year, depending on what reviewers find.

Which States Are Affected?

PPEO currently applies to hospices in six states:

  • Arizona (original)
  • California (original)
  • Nevada (original)
  • Texas (original)
  • Georgia (added December 30, 2025)
  • Ohio (added December 30, 2025)

CMS cited marked increases in reports of hospice fraud, waste, and abuse, as well as rapid growth in hospice enrollment in these states, as the basis for its expansion to Georgia and Ohio.

Which Hospices Are Subject to PPEO?

PPEO applies to hospices in the affected states that meet any of these criteria:

  • Newly enrolling in Medicare — Any hospice initially enrolling in the Medicare program
  • Change of ownership (CHOW) — Hospices undergoing a change of ownership under 42 CFR 489.18
  • 100% ownership change — Any complete change in ownership structure
  • Reactivating enrollment — Hospices reactivating their Medicare enrollment and billing privileges after being in a deactivated status (added in 2025)

For Georgia and Ohio specifically, hospices meeting these definitions on or after December 30, 2025 are subject to PPEO.

What Happens During PPEO?

During the Provisional Period of Enhanced Oversight, your hospice will face:

Expanded Prepayment Review (EPR)

CMS may place your hospice on 100% prepayment review, meaning every single claim you submit will be held and reviewed before payment. You'll receive Additional Documentation Requests (ADRs) requiring you to submit supporting documentation for each claim.

Intensive Documentation Scrutiny

Reviewers will examine your claims and documentation looking for:

  • Evidence of medical necessity for hospice care
  • Proper certification and recertification documentation
  • Complete and accurate clinical records
  • Compliance with hospice Conditions of Participation
  • Appropriate billing practices

No Guarantee of Education or Additional Review

Unlike some other CMS programs, PPEO does not require CMS to provide education or allow additional records to be reviewed. If reviewers find problems, they can move directly to enforcement action.

The Consequences Are Severe

The numbers tell the story: of 817 hospices subject to PPEO review through December 2025, 181 had their Medicare enrollment revoked. That's a 22% revocation rate.

Actions CMS can take after PPEO review include:

  • Revocation of Medicare billing privileges — You can no longer bill Medicare
  • Termination from the Medicare program — Complete removal from Medicare participation
  • Termination with a re-enrollment bar — Banned from re-enrolling in Medicare for a specified period (typically 1-3 years)
  • Extended prepayment review — Continued 100% claim review even after PPEO ends
  • Claim denials and overpayment demands — Required to repay claims deemed improper

For hospices that depend on Medicare reimbursement—which is virtually all hospices—losing Medicare enrollment means closing your doors.

How to Survive PPEO

If your hospice is subject to PPEO, or will be soon, preparation and documentation are everything.

1. Ensure Airtight Eligibility Documentation

The most common PPEO findings relate to hospice eligibility. For every patient, you must be able to demonstrate:

  • Terminal prognosis of six months or less if the disease runs its normal course
  • Physician certification with specific clinical findings supporting the prognosis
  • Face-to-face encounter documentation (for recertification periods)
  • Clear documentation of decline and disease progression

2. Respond to ADRs Strategically

When you receive Additional Documentation Requests:

  • Respond within the deadline—late responses result in automatic denials
  • Submit complete documentation, not just the minimum requested
  • Include cover letters explaining how documentation supports the claim
  • Keep copies of everything you submit

3. Appeal Every Denial

Claim denials during PPEO can compound quickly. Appeal every denial through the proper channels:

  • Redetermination (first level appeal to MAC)
  • Reconsideration (Qualified Independent Contractor review)
  • ALJ hearing if necessary

Many PPEO denials are overturned on appeal when proper documentation is presented.

4. Monitor Your Medical Director's Affiliations

CMS tracks relationships between hospice medical directors and other hospices. If your medical director is affiliated with a hospice that's had PPEO problems, it can increase scrutiny on your organization. Know your medical director's other affiliations, especially with new hospices or those undergoing ownership changes.

5. Get Expert Help Early

If you receive notice that you're being placed on PPEO or EPR—or if you start receiving ADRs without explanation—seek expert guidance immediately. The decisions you make in the first weeks of PPEO can determine whether your hospice survives.

PPEO Consulting Services

At Hospice Engine, we offer PPEO Consulting to help hospices prepare for and navigate the Provisional Period of Enhanced Oversight.

Our consultants understand what CMS reviewers are looking for and can help you:

  • Audit your documentation before PPEO begins
  • Identify and fix eligibility documentation gaps
  • Develop ADR response strategies
  • Prepare appeals for denied claims
  • Train staff on documentation requirements

PPEO Consulting: $300/hour

Don't become one of the 22% of hospices that lose their Medicare enrollment during PPEO. Our consulting services help you prepare, respond, and survive enhanced oversight.

Schedule a Consultation

Questions About PPEO?

CMS has established a dedicated email for PPEO questions: ProvisionalPeriod@cms.hhs.gov

For more information, see the CMS MLN Fact Sheet on PPEO.

The Bottom Line

PPEO is CMS's most aggressive hospice enforcement tool, and it's expanding. With a 22% revocation rate among reviewed hospices, this is not something to take lightly.

If you're a new hospice, reactivating your enrollment, or undergoing a change of ownership in Arizona, California, Nevada, Texas, Georgia, or Ohio, assume you will face PPEO. Prepare your documentation now, before the ADRs start arriving.

Your Medicare enrollment—and your business—depends on it.