Federal oversight of home health and hospice agencies is entering a more aggressive and coordinated phase. Recent actions by the Centers for Medicare & Medicaid Services (CMS), combined with accreditation-level responses from ACHC, signal a clear shift:
Agencies operating in certain states should expect more frequent scrutiny, shorter notice, and higher consequences for noncompliance.
*This article was written in consultation with Mariam Treystman.
At The Home Health Consultant (THHC), we work with Medicare-certified home health and hospice agencies on compliance infrastructure, survey readiness, and regulatory risk management. We’re writing this article to explain:
- What’s changing in CMS oversight and ACHC survey activity
- Why these changes increase survey and enforcement risk for certain agencies
- How home health and hospice providers should prepare for these updates
This is not about fear-based messaging. It’s about understanding how CMS enforcement trends and accreditation responses intersect. And making sure your agency knows how to react.
Why Is CMS Increasing Oversight of Hospice and Home Health Providers?
To understand the downstream impact on agencies, it’s important to first understand what caused CMS to act.
CMS has been explicit about the rationale behind its expanded oversight efforts. The agency has cited rising concerns related to fraud, waste, abuse, and market oversaturation, particularly in certain geographic areas.
According to CMS communications and industry reporting, the number of newly enrolled hospices has increased significantly in states such as:
- Arizona
- California
- Nevada
- Texas
This growth has prompted heightened concern about improper billing practices, insufficient service delivery, and ownership changes designed to evade enforcement. CMS has also cited reports of beneficiaries being enrolled in hospice without appropriate eligibility. Patterns of license “flipping” and minimal service provision have further contributed to these concerns.
These issues are not theoretical. CMS and the U.S. Department of Justice have publicly stated that hospice fraud investigations are now a priority.
Billions of dollars in suspected improper billing have been referred for enforcement, and thousands of providers have lost Medicare billing privileges in recent years.
One of the most direct ways CMS has responded to these concerns is through enhanced enrollment oversight.
What Is the Provisional Period of Enhanced Oversight (PPEO) for Hospices?
One of the most significant enforcement tools CMS is using is the Provisional Period of Enhanced Oversight (PPEO) for certain hospices.
Under PPEO, newly enrolling hospices (or hospices undergoing specific ownership changes) are subject to enhanced medical review. Enhanced medical review can include but is not limited to a prepayment review of claims, for a defined period.
CMS has stated that this period can last anywhere from 30 days to one year, depending on the agency’s circumstances and findings during review.
Importantly, PPEO does not apply only to brand-new startups. CMS defines “new hospices” for PPEO purposes to include agencies that:
- Are newly enrolled in Medicare
- Have undergone a change of ownership meeting regulatory thresholds
- Have reactivated after a period of deactivation
- Have experienced a 100% ownership change outside standard CHOW parameters
Hospices that received final Medicare approval on or after July 13, 2023, or that had pending enrollment or ownership actions after that date, may fall within the scope of PPEO depending on their state and circumstances.
Important Note: CMS has not applied PPEO uniformly across the country, making geography a critical factor.
Which States Are Currently Under CMS Enhanced Oversight?
As of the writing of this article, CMS has implemented PPEO in the following states:
- Arizona
- California
- Nevada
- Texas
- Georgia
- Ohio
CMS has stated that these states were selected due to a combination of:
- High growth in hospice enrollments
- Documented reports of fraud, waste, and abuse
- Evidence of market saturation raising program integrity concerns
For agencies operating in these states, the regulatory environment is going to look a bit different than the rest of the country. The tolerance for documentation errors, delayed responses, or incomplete compliance systems is significantly lower.
How Is ACHC Responding to CMS’s Increased Oversight Expectations?
ACHC has acknowledged the increased scrutiny facing hospice and home health providers. They’re also making changes to align their oversight approach with CMS’s heightened enforcement.
ACHC has announced that it will conduct select focus surveys for a limited number of home health and hospice agencies in states under enhanced CMS oversight. Again, as of the writing of this article, these states include:
- Arizona
- California
- Georgia
- Nevada
- Ohio
- Texas
These are targeted, one-day focus surveys, designed to assess compliance readiness in high-risk environments. Focus surveys will be conducted on a select, ongoing basis to ensure agencies are maintaining compliance standards between full reaccreditation cycles.
From a practical standpoint, this means accreditation is no longer something agencies should expect to address only every three years. This makes staying survey-ready year-round all the more important.
It also means understanding how these focus surveys function is essential for interpreting the real-world impact.
What Can Agencies Expect from the New ACHC Focus Surveys?
While ACHC focus surveys are intended to support compliance readiness, they still carry real consequences.
Based on information shared by ACHC and reinforced through industry communications, these surveys:
- Are typically one day in length
- Do not carry an additional cost unless conditional deficiencies are identified
- Focus on areas most likely to raise CMS concerns, including clinical records, administrative systems, and HR files
For agencies that are not operationally aligned across departments, a focus survey can surface gaps that might otherwise go unnoticed, until a complaint investigation or CMS-directed review occurs.
Notice how we’ve been saying ‘agencies’ instead of just ‘hospice agencies.’ Although hospice has been the most visible enforcement target, the implications extend further.
Does CMS’s Increased Oversight Apply Only to Hospice Agencies?
Although much of the CMS fraud narrative has centered on hospice, home health agencies should not interpret these developments as hospice-only issues.
CMS has made it clear that program integrity efforts apply to all providers receiving Medicare funds, particularly those undergoing enrollment changes or operating in high-risk markets.
Home health agencies in enhanced oversight states should expect:
- Greater scrutiny of enrollment data and ownership disclosures
- Increased likelihood of medical review activity
- Less flexibility when deficiencies point to systemic compliance failures
Accreditation surveys are increasingly being viewed as a front-line compliance checkpoint, not merely a credentialing exercise.
How Do These CMS and ACHC Updates Affect Agencies in Practice? (Q&A)
Q: Should agencies expect more surveys or interim reviews?
A: In enhanced oversight states, yes. CMS PPEO and ACHC focus surveys increase the likelihood of survey activity between reaccreditation cycles.
Q: Are ACHC focus surveys the same as a full accreditation survey?
A: No. They are shorter and targeted, but they are still formal surveys and can result in deficiencies if standards are not met.
Q: What areas are most likely to be reviewed?
A: Including but not limited to clinical records, administrative compliance systems, and HR files. Notably, CMS has identified historical risk.
Q: What puts agencies at the highest risk right now?
A: Fragmented compliance oversight, outdated documentation systems, and reactive survey preparation.
How Can Agencies Stay Aligned With CMS’s Rapidly Changing Compliance Expectations?
Enhanced CMS oversight and ACHC focus surveys reinforce a reality many agencies are already experiencing: reactive compliance was not sustainable before, but now it’s even less so.
CMS expects continuous operational compliance supported by systems that evolve alongside regulatory guidance, enforcement trends, and accreditation standards.
At The Home Health Consultant, our services are intentionally built and consistently updated to align with CMS’s rapidly changing expectations. We help agencies maintain survey readiness across clinical, administrative, and HR functions—year-round, not just at reaccreditation.
If you need help preventing deficiencies or want clarity on how these CMS and ACHC updates apply to your agency, request a free strategy call with THHC.
We’ll walk through your current compliance strategies, identify risk areas, and help you determine the level of support that best fits your agency’s needs.
*Disclaimer: The content provided in this article is not intended to be, nor should it be construed as, legal, financial, or professional advice. No consultant-client relationship is established by engaging with this content. You should seek the advice of a qualified attorney, financial advisor, or other professional regarding any legal or business matters. The consultant assumes no liability for any actions taken based on the information provided.
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