Hospice operators under intensified medical-review and TPE oversight.
The engagement
Defensible eligibility and recertification narratives built to the terminal-prognosis standard; a HOPE-ready documentation workflow; a written read on your exposure against the aggregate cap; ADR and TPE response packets answered to the contractor’s own criteria; and — where a matter turns — citation-grade investigative findings that hold under cross-examination.
Week 1 — intake: scope, audit posture, and exposure. Weeks 2–4 — eligibility and recertification record review against the standard, with gaps flagged while they can still be corrected. Ongoing — narrative coaching, pre-bill review, and audit response as demands arrive. When the situation is acute — an active ADR, a TPE round, an enrollment action — we compress the timeline and lead with the response.
Regulatory context
Hospice sits under the most active federal oversight in its history, and the documentation bar moved twice in the last year. The HOPE assessment tool replaced the Hospice Item Set on October 1, 2025, adding timed symptom-follow-up visits and structured assessment windows — the record now has to show ongoing evaluation, not a point-in-time snapshot; falling below 90% HOPE submission triggers a 4% payment penalty.
On enforcement, CMS escalated from heightened oversight of newly-enrolled hospices in six states (Arizona, California, Georgia, Ohio, Nevada, and Texas) to a nationwide six-month enrollment moratorium imposed May 13, 2026; as of mid-2025, 668 hospices were under Period of Enhanced Oversight medical review, with 122 revoked. The Special Focus Program — CMS’s mechanism to name and concentrate on poor performers — was suspended on February 14, 2025 pending stakeholder input, but the underlying scrutiny did not pause. And the FY2026 aggregate cap is $35,361.44: payments above the per-beneficiary cap are repaid, which makes length-of-stay and live-discharge patterns a standing exposure.
Net: a hospice’s risk is driven less by the care delivered than by how defensibly the record establishes — and re-establishes — a terminal prognosis.
From revenue cycle through audit defense — each shaped to your operation.
The cross-cutting capabilities we bring to hospice operators — especially the ones designated as high-risk:
Each service shaped to the specific pressure observed.
(Authorizations apply far less to hospice than to other settings; the emphasis here is eligibility, documentation, and audit defense.)
Three reasons hospices choose us:
Eligibility documentation as clinical and audit discipline together. The decline narrative has to work for the clinical team and for the medical reviewer. We build it for both.
TPE response engineered to close. Round-one work designed to end the probe, not invite the next round.
Level-of-care defense that holds. GIP, continuous care, respite — the categories most often clawed back. Our documentation closes those gaps.
Does HOPE change what we document day to day?
Yes. HOPE adds timed symptom-follow-up assessments, so the record must show ongoing evaluation at defined intervals, not a single admission snapshot. Submitting less than 90% of required HOPE data costs 4% of payment.
What actually triggers a hospice TPE or UPIC review?
Outlier length-of-stay, diagnosis mix, late or missing face-to-face encounters, and live-discharge patterns. The review tests whether the clinical record supports the six-month prognosis — not whether the care was good.
How is the cap calculated, and why does it matter now?
Aggregate payments are measured against a per-beneficiary cap ($35,361.44 for FY2026); anything over is repaid. Long lengths of stay push you toward the cap and draw audit attention at the same time.
We just got an ADR — what’s the first move?
Calendar the deadline, pull the full record for the dates in question, and build the response to the contractor’s criteria — eligibility narrative, face-to-face, recertification, and the clinical support — not to general best practice. We run it as a case file.
We were flagged as an outlier, or our payments were suspended — what now?
Move immediately: a 42 CFR 405.371 suspension gives you 15 days to rebut, and the investigation runs after the money stops. We assemble the eligibility, recertification, and live-discharge record to answer the allegation, and work the rebuttal and appeal in parallel.
Are you a law firm?
No. We’re clinicians who became investigators — LVN, Texas PI, CFE, RAC-CT — and we read the prognosis narrative the way a medical reviewer does. We work alongside your counsel and can testify as experts. Nothing here is legal advice.
Tell us what you are up against. Scoping memo in week one, before any meaningful commitment.