Medicare's Pre-payment Provisional Period of Enhanced Oversight
Medicare's Pre-payment Provisional Period of Enhanced Oversight (PPEO) is a review process for certain hospice providers, particularly new or newly acquired ones, in high-risk states like California, Nevada, Texas, and Arizona, designed to ensure compliance and reduce fraud. Reviews involve medical record and billing reviews, can last up to a year, and if a provider doesn't resolve issues, they may face penalties or termination from the Medicare program. The program's goal is to protect Medicare's integrity by identifying and addressing fraudulent or non-compliant practices, such as the "churn and burn" scheme where fake hospices open and close to pocket payments.
- Pre-payment review: This is a medical review of hospice claims before Medicare makes payment.
- Enhanced oversight: It's a more intensive review compared to standard oversight.
- Provisional period: The review period is a temporary measure, often lasting a year, but can be extended based on findings.
- New hospices: Newly enrolling hospices in specific states.
- Reactivated hospices: Providers who were previously inactive and are reapplying.
- Hospices undergoing ownership changes: Providers who submit a change of ownership that meets certain criteria.
- Targeted States: The program has been expanded in states with significant hospice enrollment increases and concerns about fraudulent activity, including California, Nevada, Arizona, and Texas.
1. Medical Review: The hospice's medical records and billing information are collected and reviewed.
2. Focus on Compliance: The review determines if services meet Medicare's coverage, coding, billing, and medical necessity requirements.
3. Education: Like other programs, PPEO can involve education to help providers correct issues, but it may be less forgiving than other programs.
4. Enforcement Actions: If a hospice doesn't comply, it may face other enforcement remedies or even termination from the Medicare program.
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To reduce fraud and abuse:The program aims to combat schemes like "churn and burn," where fraudulent hospice operations repeatedly enroll, bill Medicare, and shut down.
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To ensure compliance:It ensures that hospices are meeting all Medicare rules and providing appropriate care to beneficiaries.
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To protect program integrity:By scrutinizing high-risk providers, Medicare can maintain the financial health and trustworthiness of the hospice benefit.