Recently the Centers for Medicare & Medicaid Services (“CMS”) announced in a newly released MedLearn Matter (MLN7867599, July 2023) that effective as of July 13, 2021, any “new hospice agency” located in the states of Texas, California, Arizona and Nevada will be placed in a “provisional period of enhanced oversight” for up to a 12-month window in effort to eliminate or reduce fraud, waste and abuse. 

During this period the “enhanced oversight” shall include placing the new hospice agency under medical review, such as prepayment review.  CMS did not expand further on what “enhanced oversight” will entail, but the policy is a reaction to increased reports of fraud, waste and abuse, and a recent increase in hospice enrollment.  The agencies affected by this announcement, the way agencies can expect to be notified, and the timing are discussed below.

Per this MLN, a “new hospice agency” includes those hospices which, as of July 13, 2023:

• Newly enrolled in Medicare program;

• Submitted a change of ownership (CHOW) application, per 42 CFR 489.18; and

• Experienced a 100% ownership change that doesn’t fall under 42 CFR 489.18.

To eliminate confusion, CMS indicates that this includes hospice agencies that:

• Received their final approval for Medicare enrollment on or after July 13, 2023;

• Started the enrollment or certification process before July 13, 2023, but haven’t received a final approval letter from their MAC as of that date; and

• Receive(d) approval on a CHOW request on or after July 13, 2023.

CMS indicates that hospice agencies placed under “enhanced oversight” will receive correspondence to that effect by mail to the correspondence address on file in PECOS.  Such notice will include the following:

• Effective date of the “enhanced oversight” period;

• Duration of the “enhanced oversight” period;

• Notice that CMS may conduct a medical review of all claims and that failure to respond to such requests may result in the denial of the provider’s claims or revocation of the provider’s Medicare enrollment.

Though the period of “enhanced oversight” will start July 13, 2023, not every hospice will have the same start date. Each hospice will have an individual effective date in their final approval letter approving their recent enrollment application. The period of “enhanced oversight” for each hospice will also vary and can be between 30 days to one year. Even after the period of “enhanced oversight” ends, CMS has the right to perform medical reviews on enrolled hospices under Section 1833(e) of the Social Security Act.

A full text of the MedLearn Matter publication can be found here