PPEO ADR Support

Where PPEO is in effect

CMS launched PPEO in the four states with the worst hospice fraud signals: Arizona, California, New Mexico, and Texas. As of December 2025 / January 2026, it's expanded to Georgia and Ohio. If you're a new hospice or just bought one in any of those six states, this is your reality.

How PPEO works

It's not a routine survey or a TPE round. It's a per-claim prepayment ADR regime that lasts 30 days to 12 months, with extensions possible based on findings. Every claim you submit gets an ADR letter from your MAC requiring full supporting documentation. You don't get paid until they review and approve.

What goes in the documentation packet for each claim:

• Signed Election Statement with all required elements
• Election Statement Addendum when applicable
• Face-to-face encounter documentation with attestation, NP/MD credentials, date inside the required window
• Initial 90-day certification of terminal illness with physician narrative supporting 6-month prognosis
• Recertification for every subsequent benefit period
• Plan of Care with measurable goals, current
• IDT meeting notes documenting interdisciplinary review
• Visit notes supporting the level of care billed

Why most PPEO denials happen

It's almost never about clinical eligibility. It's about technical documentation:

• Missing or unsigned election statement addendums
• F2F encounter outside the 30-day window
• Physician narrative that says "patient declining" without the clinical specifics that justify a 6-month prognosis
• IDT notes missing required disciplines or dates
• Recertifications signed late

These are fixable patterns — if you catch them before the chart goes out the door for ADR response.

How we help

• Per-claim ADR readiness review — we look at your packet before you submit it
• Technical integrity check on signatures, dates, credentials, required forms
• Pattern detection across your submissions — if 8 of your 10 charts have the same gap, we catch it
• Election, addendum, F2F, IDT structure recommendations that map to what reviewers expect
• Templates and checklists for your team so the next round is faster

What it costs