0
Program for Evaluating Payment
Patterns Electronic Report

Can PEPPER Help Cover Your
Assets?
Kimberly Hrehor
November 5, ...
Program for Evaluating Payment
Patterns Electronic Report

Compliance Program Elements:
1.
2.
3.
4.

Compliance policies &...
Program for Evaluating Payment
Patterns Electronic Report

What is PEPPER?
 A comparative report that
summarizes a provid...
Program for Evaluating Payment
Patterns Electronic Report

Why are SNFs Receiving PEPPER?
CMS is tasked with protecting t...
Program for Evaluating Payment
Patterns Electronic Report

What are the Risks?
Office of Inspector General (OIG) FY 2013 ...
Program for Evaluating Payment
Patterns Electronic Report

Office of Inspector General Report
“Inappropriate Payments to ...
Program for Evaluating Payment
Patterns Electronic Report

SNF PEPPER Target Areas
Target Area

Coding
of ADLs

Target Are...
Program for Evaluating Payment
Patterns Electronic Report

SNF PEPPER Target Areas, cont.
Target Area

Therapy

Target Are...
Program for Evaluating Payment
Patterns Electronic Report

9
Program for Evaluating Payment
Patterns Electronic Report

How to Use PEPPER
Determine how your facility compares to othe...
Program for Evaluating Payment
Patterns Electronic Report

SNF PEPPERs
Mailed Aug. 30, 2013
– Check internally for
envelo...
Program for Evaluating Payment
Patterns Electronic Report

12
Program for Evaluating Payment
Patterns Electronic Report

Future PEPPER Plans
Next release planned for May 2014
Will su...
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ATX21 Keynote - "Can PEPPER Help Cover Your Assets?"

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Transcript of "ATX21 Keynote - "Can PEPPER Help Cover Your Assets?""

  1. 1. Program for Evaluating Payment Patterns Electronic Report Can PEPPER Help Cover Your Assets? Kimberly Hrehor November 5, 2013
  2. 2. Program for Evaluating Payment Patterns Electronic Report Compliance Program Elements: 1. 2. 3. 4. Compliance policies & procedures, standards of conduct Compliance office & compliance committee This is where Open lines of communication PEPPER can Training & teaching help! 5. Monitoring & auditing 6. Response to detected deficiencies 7. Enforcement of disciplinary standards 2
  3. 3. Program for Evaluating Payment Patterns Electronic Report What is PEPPER?  A comparative report that summarizes a provider’s Medicare claims data statistics in areas identified as at risk for improper Medicare payments.  Available for short-term and long-term acute care hospitals, critical access hospitals, inpatient psychiatric facilities, inpatient rehabilitation facilities, partial hospitalization programs, hospices and now SNFs. 3
  4. 4. Program for Evaluating Payment Patterns Electronic Report Why are SNFs Receiving PEPPER? CMS is tasked with protecting the Medicare Trust Fund from fraud, waste and abuse. The provision of PEPPER supports CMS’ program integrity activities. PEPPER is intended to help providers assess their risk for improper Medicare payments. PEPPER cannot identify payment errors! 4
  5. 5. Program for Evaluating Payment Patterns Electronic Report What are the Risks? Office of Inspector General (OIG) FY 2013 work plan, OIG compliance program guidance (2000 and 2008) – Quality of care –Billing integrity – – – – Cost reporting Anti-kickback HIPAA Etc. 5
  6. 6. Program for Evaluating Payment Patterns Electronic Report Office of Inspector General Report “Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More than a Billion Dollars in 2009”, November 2012 Identified 25% of SNF claims billed in error  Available at http://oig.hhs.gov/oei/reports/oei-02-0900200.pdf 6
  7. 7. Program for Evaluating Payment Patterns Electronic Report SNF PEPPER Target Areas Target Area Coding of ADLs Target Area Definition Therapy RUGs with High ADLs N: count of days billed with RUG equal to RUX, RVX, RHX, RMX, RUC, RVC, RHC, RMC, RLB D: count of days billed for all therapy RUGs Nontherapy N: count of days billed with RUG equal to SSC, CC2, RUGs with CC1, BB2, BB1, PE2, PE1, IB2, IB1 in RUG III; HE2, High ADLs HE1, LE2, LE1, CE2, CE1, BB2, BB1, PE2, PE1 in RUG IV D: count of days billed for all nontherapy RUGs Change of N: count of assessments with AI second digit “D” Therapy D: count of all assessments Assessment 7
  8. 8. Program for Evaluating Payment Patterns Electronic Report SNF PEPPER Target Areas, cont. Target Area Therapy Target Area Definition Ultrahigh Therapy RUGs N: count of days billed with RUG equal to RUX, RUL, RUC, RUB, RUA D: count of days billed for all therapy RUGs Therapy RUGs N: count of days billed for all therapy RUGs D: count of days billed for all therapy and nontherapy RUGs 90+ Day N: count of episodes of care at the SNF with LOS Episodes of 90+ days Care D: count of all episodes of care at the SNF 8
  9. 9. Program for Evaluating Payment Patterns Electronic Report 9
  10. 10. Program for Evaluating Payment Patterns Electronic Report How to Use PEPPER Determine how your facility compares to other SNFs If statistics higher/lower than most other SNFs (“outlier”), ask “why?” Consider patient population, external factors Review documentation: does it support the MDS? RUG assignment? If yes – note results of audit; reassess periodically; maintain documentation of audits If not – take necessary steps to address issues; reassess; continue to adjust if necessary 10
  11. 11. Program for Evaluating Payment Patterns Electronic Report SNF PEPPERs Mailed Aug. 30, 2013 – Check internally for envelope PEPPERresources.org – SNF PEPPER user’s guide – Recorded training sessions – Help Desk – Sample SNF PEPPER – Other resources 11
  12. 12. Program for Evaluating Payment Patterns Electronic Report 12
  13. 13. Program for Evaluating Payment Patterns Electronic Report Future PEPPER Plans Next release planned for May 2014 Will summarize statistics for FYs 2011, 2012, 2013 Any updates will be communicated through our listserv, CMS, national/state associations 13
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