This transcript has been auto generated
00;00;00;00 - 00;00;33;18
Bryan Nowicki
Hello and welcome to Hospice Insights: The Law and Beyond, where we connect you to what matters in the ever changing world of hospice and palliative care. PPEO Playbook: The High Stakes Game Hospices Can’t Afford to Lose. Hey, Claire, how you doing? And thanks for joining me on the podcast. I’m getting my feet wet with hosting duties. I’ve never been a professional podcaster at this point, but I’ve got big shoes to fill with Meg’s retirement.
00;00;33;18 - 00;00;35;25
Bryan Nowicki
But I’m glad to have people like you to help me through it.
00;00;35;28 - 00;00;42;01
Claire Postman
Yes, well, you’re doing a great job, Bryan, and it is always a pleasure to be on the podcast.
00;00;42;04 - 00;01;13;06
Bryan Nowicki
All right. Great, great. Well, we have some timely topics to talk about. We’re doing a series of podcasts. So kind of my my baptism by fire is an era where there’s enhanced enforcement. And not only that, but it’s sweeping the nation. Claire, you and I have done a lot of work on this enhanced enforcement area over the past couple of years in those four western states Arizona, California, Nevada, Texas, there’s been this provisional period of enhanced oversight.
00;01;13;08 - 00;01;39;26
Bryan Nowicki
There’s been expanded 100% prepayment review, all sorts of stuff going on. And now, December 2025 comes around and they’re expanding that enhanced oversight to Ohio and Georgia. They started in those four Western states, I think, because they were seen as kind of the hotbeds of potential fraud. Ohio and Georgia, you know, not so much as the four Western states, but they’re certainly going down their list.
00;01;39;26 - 00;01;58;04
Bryan Nowicki
And I think they're just going to add more states to it. So I think it’s timely that we update our Ohio and Georgia friends to what our experience has been, so they can know what to expect and maybe how to prepare for that. And I’m glad to have your experience in this to help us, alert those folks.
00;01;58;04 - 00;02;05;06
Bryan Nowicki
So why don’t we get started just with the basics? What is a PPEO and why should people care about it?
00;02;05;08 - 00;02;43;23
Claire Postman
PPEO stands for Provisional Period of Enhanced Oversight and essentially what it is. It's a claim review for a select group of providers. So it impacts quote unquote new providers in the state that you just mentioned, Bryan, Arizona, California, Nevada, Texas, and now Georgia and Ohio. New is a bit of a misnomer because it applies to not only newly enrolling hospices, which is what I think of when I hear new provider, but also to providers that have undergone a recent change of ownership.
00;02;43;23 - 00;03;16;28
Claire Postman
And that means a true core of the hospice or a 100% change in the owners through a toy, and then also providers that have recently reactivated. So it’s this group of providers in these select states, and it’s a claim review essentially of their submitted claims. You’ll get a series of the address and maybe I’ll pause there and we can talk a little bit about the process, but it’s essentially a way of checking on these quote unquote new providers and these states.
00;03;17;01 - 00;03;43;08
Bryan Nowicki
Yeah. And so I think one of the reasons why this should get everybody’s attention is what can happen if things don’t go well for you. So, this is not just an ADR where you claim is reviewed and you get denied or paid, and maybe you appeal it and it’s $5,000 a claim and all that. What is waiting for a hospice who does not fare well in one of these?
00;03;43;08 - 00;03;44;09
Bryan Nowicki
Well, what are they looking at.
00;03;44;09 - 00;04;10;28
Claire Postman
Yeah, that’s that’s exactly right. So there are very drastic consequences to not performing well in a PPEO. And you know, we’ll talk a little bit about what the process looks like. But performing well in a PPEO can mean different things. We’ve seen kind of different processes across these states. But if hospice doesn’t perform on this claim review, we have seen hospices being revoked.
00;04;10;28 - 00;04;38;19
Claire Postman
So their billing privileges, their Medicare enrollment being revoked, and then there’s downstream consequences of that revocation. So hospices are actually seeing, you know, if the hospices revoked them, their medical director is revoked due to an affiliation with the hospice. And then it can go even further, a step further. So any other hospice that has the same medical director as the initially revoked hospice may see their enrollment revoked.
00;04;38;21 - 00;05;03;29
Claire Postman
So drastic consequences not only for the initial hospice that is subject to the PPEO, but also to the hospices, medical directors, other hospices that might be affiliated with the same medical director. Those are kind of the most drastic consequences. But, you know, there's a host of options that CMS may choose depending on how a hospice does during the PPEO process.
00;05;04;01 - 00;05;18;23
Claire Postman
So we’ve seen hospices be put into TP following a PPEO review. So there’s kind of a range of potential consequences, the most serious of which. And unfortunately it hasn't been uncommon is revocation.
00;05;18;29 - 00;05;42;02
Bryan Nowicki
Yeah I know in the cases you and I have worked on that seems to be the default. You’re going to get revoked if you don't do well. Revocation of billing privileges. And we’ve seen that in a notice that would come through your your billing privileges will be revoked 30 days from the date of the notice. We’ve seen it come in that your billing privileges are revoked, retroactive several months.
00;05;42;05 - 00;06;02;02
Bryan Nowicki
And like you said, this whole domino effect. Claire, you and I are working on a case going to an administrative law judge where one of our clients, medical directors, was part of another hospice that was subjected to a PPEO and was revoked. And now this guilt by association, somewhat has put our client into the hot seat.
00;06;02;03 - 00;06;27;26
Bryan Nowicki
And I remember, you know, this is going back a bit further, shows how long you and I have been working on this, but I remember, where one, hospice got revoked and then they went ahead and extended that revocation to another hospice that was under common ownership. So a lot of varieties of ways that they can really turn a claim review into fraud and drastic consequences, like you said.
00;06;27;29 - 00;06;48;17
Bryan Nowicki
Well, let’s take it back to the beginning there. Now that we've gotten everybody’s attention, I guess, about why this matters. How does a PPEO begin? We know it’s new hospice is, and we'll have another podcast about that, a deeper dive in that topic itself. But but tell us how they begin. How does this whole thing unfold.
00;06;48;19 - 00;07;12;17
Claire Postman
Yeah. So starts with the triggering event. So you know, you’re newly enrolled for example, your new hospice, you ideally would receive a letter that we have seen some hospices actually receive that letter notifying them that they are going to be subject to a PPEO. We have seen lots of hospices that haven’t gotten that letter, and instead they just start getting aiders.
00;07;12;18 - 00;07;45;18
Claire Postman
If you have one of these kind of triggering events for a PPEO and now you get an ADR, you should be able to identify from that ADR whether the ADR is part of a PPEO as opposed to a TB or some other type of claim review. So if you actually go into your ADR, it'll have some language that will say something like this ADR is part of a PPEO, so it's generally kind of one of those two things, either a letter or and ADR that includes language that sends you your part of a PPEO.
00;07;45;26 - 00;07;54;20
Bryan Nowicki
All right. And so, tell us what the initial set of reviews look like. What kinds of claims are they looking at? Well, how many claims, what time period?
00;07;54;23 - 00;08;20;07
Claire Postman
Yeah. And here’s where that profile gap. You know, the only thing we know for certain is that PPEO can last from 30 days to a year. That's what's in the statute. That's what's in the regulation. Everything else, what we’ve seen from working with a number of hospices, but it’s been a little bit all over the place. Typically what we'll see is a first round of claim review where ten claims, generally ten claims.
00;08;20;09 - 00;08;46;07
Claire Postman
Once you've submitted your responses to those ten claims, you’ll start getting decisions on those ten claims. So those decisions will likely come in through remittance advice on the individual claims in your system. And then once all of the ADR seventh minute, they've all been reviewed. Decisions have been issued for all ten claims. CMS will go ahead and share a notice of your review results.
00;08;46;09 - 00;09;08;21
Claire Postman
That will give kind of a summary of that first round. The PPEO will tell you, kind of how many of the claims were approved, how many were denied, and then what the next steps are going to be. Most likely again, it will most likely tell you what the next steps are going to be. So for example, it may say you’re being moved to round two of PPEO.
00;09;08;24 - 00;09;32;15
Claire Postman
It may say you’re being referred to CMS for follow up action. I would say when we first started seeing these, we were seeing Max more frequently offering education. After that first round of review, I would say we’ve been seeing that education offer less recently after the first round of review. So I would say that’s typically how PPEO starts with a ten claim review.
00;09;32;21 - 00;10;01;17
Claire Postman
That’s been pretty consistent. I would say, what comes after that is less consistent. So we’ve seen some providers then get moved into a 100% prepayment review. Some providers got moved into that round two like I mentioned, which is another out of ten claims. Looks very similar to the first round, except that, you know it’s going to be a new batch of ADRs. In some cases
00;10;01;19 - 00;10;36;00
Claire Postman
we’ve seen CMS proceed directly to revocation after round one, so no additional claim review, no round two. You're just moving straight to revocation. Those are kind of the three ways that we’ve seen PPEO play out. Sometimes it’s a bit of a mix and match. So we’ve seen hospices get moved into 100% prepayment review. But then ten of those claims get selected to be designated as the round two review, and the hospice will get a results letter that includes decisions for some, some group of ten of those claims.
00;10;36;00 - 00;10;39;16
Claire Postman
But that's kind of generally the process for how this works. Yeah.
00;10;39;16 - 00;11;05;29
Bryan Nowicki
And none of this is laid out. It’s not like there is a playbook that’s available to us or providers about here’s how it’s supposed to go. It’s kind of, whatever they choose to do, and they have a lot of discretion to do what they want to do in terms of a review. And I think what you and I have seen is NGS or CMS may be getting frustrated if claims aren’t coming in routinely and regularly.
00;11;06;01 - 00;11;29;05
Bryan Nowicki
We had a, a hospice client that was a new hospice, but it took them some time to begin submitting claims. And so I think it was NGS they held round one open for a few months. No claims were submitted. So they said, okay, well, round one is over. We’re going to start with round two. And so really, there was never, substantive round one.
00;11;29;07 - 00;11;53;22
Bryan Nowicki
They went right to round two and then a right to revocation. And then I think another client of ours, they did a round one, and this might have been before they came to us, they decided to stop submitting claims, thinking they might gain some advantage from that. And so I think NGS got frustrated with the lack of claims and said, okay, if you’re not going to do any claims, we'll just end this at round one.
00;11;53;22 - 00;12;22;22
Bryan Nowicki
And it didn’t do so well. So now we’re revoking you. So I think you can overthink these kinds of things in ways that you might not get the reaction from the government that you want, by the way, you submit claims and holding them, or kind of delaying them or being too selective. The only thing I know, Claire, when we've been doing these, it's the only thing we can predict is every every new PPEO is going to have some wrinkle in it that's going to be different from whatever we’ve found before.
00;12;22;27 - 00;12;35;02
Bryan Nowicki
So all right, so you’re getting these, claims reviewed in whatever process that is. Take us to the next step. What what happens next? And what kinds of things can hospices try to do to respond to that?
00;12;35;07 - 00;13;01;08
Claire Postman
In kind of the most serious situation where you’re dealing with a revocation that would come after round two, we are typically seeing that when the claims error rate is above 20% still, after around two, although, you know, for our clients who have, received revocation notices after round one, they’re applying that payment error rate only to the round one claim review.
00;13;01;09 - 00;13;23;13
Claire Postman
So they’ll do the review that the payment error rate or claim error rate is above 20%. They’ll get a notice results letter for round two or round one. If they only had one round of reviews saying that they’re likely to be referred to CMS and then within a few weeks, in some cases up to a couple months, they’ll receive a revocation notice from their MCC.
00;13;23;13 - 00;13;52;22
Claire Postman
I did mention earlier, we have occasionally CMS take different action, but generally when after round two, the hospice is very close to the 20% error rate, maybe 30% error rate, something like that. Or, you know, we know that Sims is really focused on clinical denials. So maybe error rate is a little higher, but it's mostly technical denials. Those are the cases where we may see CMS pursuing something like moving the hospice into TPA as opposed to revoking.
00;13;52;28 - 00;14;14;15
Claire Postman
But let’s talk about worst case scenario. You’ve gone through PPEO and then you get a notice of revocation. I think, Bryan, your question was about what do you do? What are the opportunities you have to advocate for yourself. So the first actually starts when you start getting your ADR decisions, which is you should appeal every claim denial that you get.
00;14;14;15 - 00;14;39;08
Claire Postman
That’s part of a PPEO. And the goal there is to reduce the claims error rate through favorable decisions in the appeal process. And that’s going to support future appeals advocacy efforts with CMS. If you do get revoked, you’ll be able to say, hey, our initial results were 60% error rate, but after appeals, we are below the 20% threshold, so we shouldn’t have been revoked.
00;14;39;10 - 00;14;42;24
Claire Postman
So appeal the claim denials first and foremost.
00;14;42;24 - 00;15;02;28
Bryan Nowicki
And Claire, I think we had a case where they got denied nine out of ten. Those were all appealed. They won all nine or they won seven out of nine or something. We kind of updated CMS and NGS to that. And he said, well, thanks for the information. We see you. You’ve done better. Or maybe we shouldn’t have gone down this path to begin with and you’re out.
00;15;02;28 - 00;15;13;16
Bryan Nowicki
So yeah, I think don’t overlook the advocacy on the individual claim denials along the way. That’s going to help your arguments as you get deeper into this. If you get deeper.
00;15;13;19 - 00;15;36;17
Claire Postman
That’s right. And, you know, there’s kind of two appeal paths here we’re going to talk about. One is appealing the claim denials. The second is appealing the actual revocation itself. And if you don’t appeal the claim denials, it’s going to be challenging to get into the merits of those claim denials in your appeal of the revocation. And so that’s why we recommend, you know, pursue both paths.
00;15;36;17 - 00;15;43;07
Claire Postman
Your appeal, the claimed emails. And then you can use those results in your appeal of your revocation.
00;15;43;10 - 00;16;07;06
Bryan Nowicki
Great. All right. And so why don't you talk about the revocation. So you know the hospices they’re taking our advice. They’re getting denied. They’re getting they’re appealing those to keep those issues alive for future use. Now they get the notice of revocation. I guess first, from a practical perspective, what do you do with all these patients if you're building privileges are going to be revoked within 30 days.
00;16;07;08 - 00;16;31;16
Claire Postman
So generally, we would recommend that you start making plans to transfer your patients in some cases. Bryan, you mentioned that case where there had been favorable appeal results, and we were able to notify CMS and NGS of those results, we were able to get that matter wrapped up informally very quickly. And so the revocation never actually went into effect.
00;16;31;16 - 00;17;00;14
Claire Postman
That is not always possible. And if you’re going through the full appeal process for a revocation, it's going to take quite some time. And there's no stay of the revocation in the interim. So we’re currently seeing that those decisions are taking, in some cases over six months for CMS to issue a decision on just the reconsideration request. And, you know, that doesn’t take into account if you then have to go to an ALJ or further appeal process.
00;17;00;14 - 00;17;34;25
Claire Postman
So those decisions are taken quite some time to come back. And that’s a period of time when the hospice is not going to be able to be reimbursed for the care that it’s providing. So we do generally recommend that the hospice start making plans to transfer patients work with counsel. You know, if you think you might be in a situation where you can get some kind of informal release, you know, it’s a case by case determination, but certainly don’t get to the 30 day point and have no plan for what happens if the revocation is going to go into effect.
00;17;34;26 - 00;18;01;05
Bryan Nowicki
Yeah. I mean, you could let’s say you you appeal the revocation and you win and you learn that you won seven months later. In the meantime, you know, if you decided to keep your patients, you’re not getting paid for doing that. You’re incurring all the costs. The elimination of the revocation is retroactive. But boy, what a risk that is to hope that you win a reconsideration five months later while you’re incurring all those costs.
00;18;01;05 - 00;18;26;16
Bryan Nowicki
So yeah, I think the hospices we’ve worked with, when we’ve talked with them and told them about the consequences, it’s planning for the transfer and hoping you’ll be able to bring them back or restart your operations, when you get some success. We’ve had some hospices kind of go that path where we got a good reconsideration decision seven months later, and then they said, okay, it was important enough for us to keep this number.
00;18;26;16 - 00;18;41;15
Bryan Nowicki
We didn’t give in. But, now we got to essentially start from scratch again. So with the with the appeals of the revocations, what are the issues that are coming up on those appeals? What kind of arguments do you need to make to win those appeals?
00;18;41;17 - 00;19;08;00
Claire Postman
So for a standard revocation, you’ve gone through 1 or 2 rounds, PPEO and then CMS revokes based on the results of that claim review. They call that, abuse of billing privileges revocation. That's the regulatory basis for them to revoke. And their grounds are essentially that the provider has a pattern or practice of submitting noncompliant claims. They’re required to consider a number of factors.
00;19;08;00 - 00;19;39;29
Claire Postman
So that includes the percentage of claims that were denied during the period under consideration, whether the provider has any previous adverse actions, that type of billing noncompliance, and then just a catchall for kind of any other information that CMS determines relevant. So kind of the key things to look at here are what’s your history if you’re a provider that maybe just had a change of ownership as opposed to a newly enrolled provider, do you have a history of favorable audit activity?
00;19;39;29 - 00;19;58;24
Claire Postman
Have you ever had other claims denied, or is the percentage of submitted claims that were denied really quite small because you’re just, you know, when you look at the whole universe and not just the ten claim samples that were included in PPEO, is it really a small percentage of the overall claims that were denied and then the type of billing noncompliance?
00;19;58;24 - 00;20;37;13
Claire Postman
If it’s a technical denial, that's something that the CMS generally isn’t considering as much of a priority for revocation. But even with a clinical denial, you know, can you make the argument that you relied on your physician’s reasonable judgment? This is kind of a reasonable disagreement between clinicians, not fraud or abuse. So kind of thinking through how you can rebut each of those factors, even if you have a 90% denial rate as part of the people review, what can you say about your overall operations, your overall history, and the compliance programs you have in place?
00;20;37;13 - 00;20;44;21
Claire Postman
And the reason that these claims were actually denied? And that’s where the claim appeals can come in and help you to if you've had some success there.
00;20;44;24 - 00;20;58;14
Bryan Nowicki
Well, now, you talked earlier about the cascading effect, the domino effect, or guilt by association. Maybe I used to guilt by association term, but what's the issue on appeal if that's the kind of revocation you’re dealing with?
00;20;58;17 - 00;21;26;12
Claire Postman
Yeah. So that's an affiliation based revocation. So so CMS is going to be looking at a different grounds there for revoking. But what they have to prove is not only that the affiliate provider was and did in fact have an affiliation, but also that that affiliation posed undue risk to the Medicare program. And so, again, there’s a number of factors that the CMS is going to have to consider.
00;21;26;15 - 00;21;54;21
Claire Postman
Things like how long did the affiliation last as the affiliation since been terminated, what was the nature of the revocation for the underlying provider that kind of triggered the domino effect. So again, there’s going to be a host of factors that you're going to want to go through and rebut. So for example, if you’ve terminated that medical director that’s linking you to a revoked hospice, you’re no longer affiliated with them.
00;21;54;21 - 00;22;11;13
Claire Postman
You’ve moved on to another medical director. That’s something you’d want to bring up in response to that factor that asks about, does this affiliation still exist, how long ago was it terminated, etc. So it’s not just an affiliation, but a key thing to remember is an affiliation that poses an undue risk.
00;22;11;15 - 00;22;46;26
Bryan Nowicki
Yeah. And I think, you know, the way you’ve described the whole process and the variability and the different, I guess, tests or, considerations, I think clear when you and I have worked these cases, what we have seen are lots of opportunities for advocacy. Like, you know, it’s not appropriate to skip around and go to right to round two, you know, there’s a lot of ways to try to convince NGS or more directly, CMS that they’re not achieving the goal of the PPEO program in the way they are proceeding.
00;22;46;28 - 00;23;08;07
Bryan Nowicki
And so I think that’s kind of what you and I have gained through experiencing a lot of variability in all this is we can kind of detect what’s different and how that might undermine the approach that NGS or increasingly, Palmetto is taking. So yeah, this this is all helpful information. People can see the ins and outs of this.
00;23;08;07 - 00;23;15;10
Bryan Nowicki
Any any parting words, Claire, or guidance or advice or words of encouragement or hope that you can share?
00;23;15;12 - 00;23;37;28
Claire Postman
I would say, you know, take this seriously from the get go. Don’t wait until you get that round one results letter. So when you’re preparing responses to your ADR, your ADR is a come in. You know that it’s a PPEO. Make sure you’re doing a super thorough review of the claims you’re submitting, potentially even involve counsel at that stage.
00;23;38;02 - 00;23;55;04
Claire Postman
You know, take this really seriously upfront because once you get that round to results letter, if you’re still above 20%, it it could be too late. You've got a revocation coming. So do everything you can to shield yourself up front with the goal of warding off any denials in the first place.
00;23;55;10 - 00;24;12;05
Bryan Nowicki
Yeah, I think, I think that’s great advice when you're thinking about how do you allocate resources. And it’s an ounce of prevention worth a pound of cure. So thanks so much, Claire, for for joining us and sharing all this information. I really appreciate it. I hope we I hope the, the listeners out there gain some value from it.
00;24;12;07 - 00;24;37;06
Bryan Nowicki
If you have any questions, you can always reach out to Claire to meet anybody on the Husch Blackwell Hospice, Home Health and Palliative Care team. We can answer any of the questions you have. Take care.
That’s it for today’s episode of Hospice Insights: The Law and Beyond. Thank you for joining the conversation. To subscribe to our podcast, visit our website at huschblackwell.com or sign up wherever you get your podcasts.
00;24;37;08 - 00;24;43;19
Bryan Nowicki
Until next time, take care.