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For most of their history, Unified Program Integrity Contractors (UPICs) looked at hospice claims after Medicare paid them. That has changed. Prepayment reviews are now coming from all three UPIC contractors. At the same time, CMS has published a hospice-by-hospice scoring tool that it says will help it decide where to send medical review. If you run a hospice, the time to get your records and your data in order is before the first ADR shows up, not after.

What changed: UPICs now review hospice claims before payment

On Husch Blackwell's Hospice Insights podcast (May 6, 2026), attorneys Bryan Nowicki and Zaina Niles said UPICs, which "historically ... almost exclusively conducted post payment reviews," are now requesting records "after claims have been billed, but before payment has ever been issued." They have seen this from all three UPIC contractors: Qlarant Integrity Solutions (Western and Southwestern jurisdictions), SafeGuard Services (Northeast and Southeast), and, most recently, CoventBridge (Midwest).

Key points from that discussion:

  • Rounds, not one big pull. Older post-payment UPIC audits asked for roughly 25–75 claims. In the prepayment reviews they described, Qlarant sent 10 ADRs, decided all 10, and then sent another 10. SafeGuard has been less likely to work in rounds. A first round of about 10–20 claims is a reasonable thing to plan for.
  • No published error-rate threshold. TPE, PPEO, and EPR reviews have known thresholds. This review type does not, at least not one the attorneys know of. They said an error rate around 50% after round one has usually led to a second round, but the exact cutoff is unclear.
  • Results so far. First-round error rates have been high with Qlarant, and hospices have done better in round two. SafeGuard has approved more claims but has also produced high error rates.
  • Referrals happen. In some cases, after a hospice answered a UPIC ADR, its regional BFCC-QIO sent its own records request focused on quality of care. That review moves quickly and has a different appeal process.

What happens after round two is still unknown.

Why your SSVI score now matters

In the FY 2027 Hospice Wage Index final rule (published August 3, 2026), CMS introduced the Hospice Service and Spending Variation Index (SSVI). It combines nine claims-based metrics:

  • Non-hospice spending score (0–8 points): Medicare Part A, B, and D spending for your patients outside the hospice benefit during their election.
  • Utilization score (0–8 points): one point each for: no CHC and no GIP during the year; 40% or more of RHC days in a nursing facility or SNF; low skilled visits in the last two days of life; a high live-discharge rate; a high share of discharges with stays over 180 days; low skilled-nursing minutes per RHC day; few weekend RHC days with a skilled visit; and a high rate of live discharges who come back to the same hospice within seven days.

The total runs from 0 to 16. CMS wrote that it "would consider a hospice with 13 or more points an outlier as it would be at 99th percentile." CMS also stated plainly how it plans to use the score: a high SSVI "may require additional targeted education or oversight, such as medical review, education, and investigations that could result in payment suspension, and revocation, if there is identified fraud, waste, or abuse."

A high score is not a finding of wrongdoing, but CMS has published the scores (FY 2024 and FY 2025 data) and said it will use them to target oversight. Know your number and what is behind each point.

The enforcement backdrop

Prepayment UPIC review is happening alongside several other actions:

  • Payment suspensions. Under 42 CFR 405.371, CMS can suspend payments based on reliable information of an overpayment or a credible allegation of fraud. The suspension itself cannot be appealed. The provider's chance to respond is a rebuttal, and Qlarant's notices allow 15 business days to file one. (Qlarant sent a wave of these suspension notices to California hospices in spring 2026.)
  • The national enrollment moratorium. CMS's six-month moratorium on new Medicare enrollment of hospices and home health agencies took effect May 13, 2026. By our estimate, the initial six-month period ends around November 13, 2026; CMS has not announced a specific end date. CMS can extend it in six-month increments and would publish any extension in the Federal Register. It does not affect hospices that are already enrolled, but it does cover certain changes in majority ownership.
  • The election statement addendum. For elections beginning on or after October 1, 2026, every patient must receive the addendum in writing within five days of the election's effective date. Updates are due within three days of a plan-of-care change that affects it. CMS's enforcement discretion runs through December 31, 2026. Until then, MACs will not deny claims solely for a missing or incomplete addendum. After that date, normal conditions of payment apply.

What to do now

1. Look up your SSVI score and break it down. Open CMS's SSVI file and find your CCN. For each utilization point, find the operational cause. For example, the point might come from a live-discharge pattern, a nursing-facility-heavy census, thin weekend coverage, or visits in the last days of life. Then look at non-hospice spending: are unrelated-condition decisions documented, and are you coordinating with outside providers?

2. Run a mock ADR on 10 charts. Pull 10 recent claims, mixing long stays, live discharges, and recertifications. Check each one the way a reviewer would. Is the certification of terminal illness complete and timely? Is there a face-to-face encounter where required? Is the election statement valid? Do the IDG notes and visit notes show decline, with measurable indicators, over the period billed? If 3 of 10 have gaps, assume a real round would look the same.

3. Make terminal prognosis easy to see. Reviewers decide eligibility from the record. Make sure narratives tie objective findings to a prognosis of six months or less: weight and intake trends, functional scores, disease-specific markers, hospitalizations, and comorbidities. The Husch Blackwell attorneys suggested putting a brief patient summary at the top of each ADR response, laying out why the patient is terminally ill and why the services were reasonable and necessary. If a claim is denied, that summary can become the starting point for a redetermination request.

4. Track every ADR in one place. Log the requesting contractor, letter date, receipt date, response deadline, claims requested, date submitted, submission method and confirmation, and the outcome. Prepayment reviews come in rounds, and the review runs on the contractor's timeline. A missed response is usually treated as a denial.

5. Respond complete, organized, and on time. Send records that answer the request, indexed by patient and claim, with nothing missing. Keep proof of delivery.

6. Finish addendum workflows before January 1. Use the grace period to make sure your intake team issues the addendum every time, documents the conversation, and updates it when the plan of care changes.

7. Know when to call counsel. A suspension or revocation notice, or a sudden jump in ADRs, warrants healthcare counsel before the response window closes.

Get help with your SSVI score

We go through SSVI scores, how they are calculated, and what to fix first in a free webinar every Friday at 10 AM PT. Register here.

If you want someone to go through your own numbers with you, we offer a one-on-one SSVI consultation for $400. We review your score components and your documentation risk areas and build a prioritized action list. Book a consultation.

This article is general information, not legal advice. Facts are current as of October 12, 2026.

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