Are You Ready for the SNF PEPPER?

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The Skilled Nursing Facility (SNF) “Program for Evaluating Payment Patterns Electronic Report” (PEPPER) is due for release April 2014. CMS introduced this new annual report for Skilled Nursing Facilities in August 2013. PEPPER data is shared with both Medicare Administrative Contractors (MACs) and the Medicare Recovery Auditor Contractors (RACs). This important report details your specific Medicare claims data in certain targeted areas and compares your facility to other SNFs Nationally, by State and by Jurisdiction (Medicare Administrative Contractors/Fiscal Intermediaries). PEPPER gives provider-specific Medicare data statistics for services vulnerable to improper payments, according to the federal government, and allows providers to see how their facility compares to all other SNFs across the state, nation or Medicare Audit Contractors(MAC) jurisdiction.

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Are You Ready for the SNF PEPPER?

  1. 1. Are You Ready for the SNF PEPPER Presented by: Elisa Bovee Vice President of Operations Harmony Healthcare International, (HHI) Copyright © 2014 All Rights Reserved 1Harmony Healthcare International, Inc.
  2. 2. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. About Elisa Elisa Bovee, MS OTR/L Elisa Bovee is the Vice President of Operations at Harmony Healthcare International, (HHI) an industry leader in Long Term Care consulting. Over 20 years of experience in the long-term care industry Appeals Coordinator for a National nursing home company Follow Me! @ElisaBovee 2
  3. 3. Objectives The learner will be able to: State three variables contributing to initiation of the PEPPER in the long-term care setting State the Pepper Target Areas. Describe CMS Comparative Data Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 3
  4. 4. Are You Ready for the SNF PEPPER How PEPPER was born; OIG Audits Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 4
  5. 5. Wall Street Journal, November 12, 2012 Thomas Burton, November 2012 “More intensive services were done than actually performed” “Patients could not benefit from it” “Cutting fraud” Obama Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 5
  6. 6. Wall Street Journal Sample 499 claims by 245 (stays) nursing facilities 1 home reached a settlement agreement on allegations of fraudulent billing for “medically unnecessary” therapy “More therapy during the period on which bills were based” “Look-Back Period” Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 6
  7. 7. OIG Report: Claims in 2009 25% billed all claims in error 1.5 billion 26% claims not supported in the medical record 542 million in over payment “Majority” error “upcoded”* Many Ultra High * Original RUG was a higher paying RUG than the revised RUG Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 7
  8. 8. OIG Report: Claims in 2009 20.30% 2.50% 2.10% 75.10% Billing Errors Issues found with skilled-nursing facilities’ Medicare claims, based on an outside review of 2009 data Properly billed Billed for a more expensive treatment than was provided Billed for a less expensive treatment than was provided Billed for a condition not covered by Medicare Source: Department of Health and Human Services Office of Inspector General Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. OIG Report: Claims in 2009 Remaining, “downcoded”* Did not meet Medicare coverage requirements 47% claims, misreported information on the MDS “SNF’s commonly misreported therapy” * If the original RUG was a lower paying RUG than the revised RUG Harmony Healthcare International, Inc. 9Copyright © 2014 All Rights Reserved
  10. 10. MedPac noted that the payment system “encourages SNF’s to furnish therapy, even when it is of little or no benefit” 20062008 SNF’s increasingly billed for higher paying categories even though beneficiary characteristics remained largely unchanged Harmony Healthcare International, Inc. 10 OIG Report: Claims in 2009 Copyright © 2014 All Rights Reserved
  11. 11. 3 RN Nurses reviewed the claims along with the PT/OT/ST Analysis Upcoded Downcoded Both considered errors Harmony Healthcare International, Inc. 11 OIG Report: Claims in 2009 Copyright © 2014 All Rights Reserved
  12. 12. Paid $1.5 billion for these claims. This represents 5.6 percent of the $26.9 billion paid to SNFs in 2009 See Table 1 for the percentage of SNF claims that were in error and Appendix D for the confidence intervals Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 12 OIG Report: Claims in 2009
  13. 13. Table 1: Percentage of SNF Claims That Were in Error - 2009 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 13 Type of Error Percentage of SNF Claims Inaccurate RUGs 22.8% Upcoded 20.3% Downcoded 2.5% Did Not Meet Coverage Requirements 2.1% Total Error Rate 24.9% Source: OIG analysis of medical record review results, 2012 OIG Report: Claims in 2009
  14. 14. SNFs billed inaccurate RUGs in 23 percent of claims. Most of these claims were upcoded; far fewer were downcoded. Claims with inaccurate RUGs amounted to a net $1.2 billion in inappropriate Medicare payments Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 14 OIG Report: Claims in 2009
  15. 15. Notably, 20 percent of claims billed by SNFs had higher paying RUGs than were appropriate In these cases, the SNFs upcoded the RUGs on the claims. For approximately half of these claims, SNFs billed for Ultra High Therapy RUGs when they should have billed for lower levels of therapy or nontherapy RUGs Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 15 OIG Report: Claims in 2009
  16. 16. For 57 percent of the upcoded claims, SNFs reported providing more therapy on the MDS than was indicated in the medical record Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 16 OIG Report: Claims in 2009
  17. 17. For a quarter of the upcoded claims, reviewers determined that the amount of therapy indicated in the beneficiaries’ medical records was not reasonable and necessary Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 17 OIG Report: Claims in 2009
  18. 18. For example, in one case, the SNF provided the highest level of therapy to the beneficiary even though the medical record indicated that the physician refused to sign the order for therapy In another example, the SNF provided an excessive amount of therapy to the beneficiary given her condition Harmony Healthcare International, Inc. 18 OIG Report: Claims in 2009 Copyright © 2014 All Rights Reserved
  19. 19. In another example, the SNF report on the MDS that speech therapy was provided even though the record contained an evaluation of the beneficiary concluding that no speech therapy was needed and that speech therapy had not been provided Harmony Healthcare International, Inc. 19 OIG Report: Claims in 2009 Copyright © 2014 All Rights Reserved
  20. 20. Two percent of SNF claims did not meet Medicare coverage requirements For some of these claims, beneficiaries were not eligible for SNF care, either because they did not need skilled nursing or therapy on a daily basis or because there were no physician orders for these services Harmony Healthcare International, Inc. 20 OIG Report: Claims in 2009 Copyright © 2014 All Rights Reserved
  21. 21. SNFs misreported information on the MDS for 47 percent of claims. SNFs reported inaccurate information, which was not supported or consistent with the medical record, on a least one MDS item for 47 percent of claims For 30 percent of claims, SNFs misreported the amount of therapy that the beneficiaries received or needed Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 21 OIG Report: Claims in 2009
  22. 22. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 22 MDS Category With Misreported Information Percentage of Claims Therapy (i.e., physical, occupational, speech) 30.3% Special Care (e.g., intravenous medication, tracheostomy care) 16.8% Activities of Daily Living (e.g., bed mobility, eating) 6.5% Oral/Nutritional Status (e.g., parenteral feeding) 4.8% Skin Conditions and Treatments (e.g., ulcers, wound dressings) 2.4% Source: OIG analysis of medical record review results, 2012 Note: The rows do not sum to 47 percent because some claims had more than on problem OIG Report: Claims in 2009
  23. 23. In addition, reviewers found several instances in which SNFs provided more therapy during the look-back period than they did during periods that did not determine payment rates Harmony Healthcare International, Inc. 23 Look Back Period Copyright © 2014 All Rights Reserved
  24. 24. In one example, the SNF provided 90 to 110 minutes of therapy a day to the beneficiary during the look-back period; however, after that period, the SNF provided only about half that amount of therapy to the beneficiary Harmony Healthcare International, Inc. 24 Therapy Minutes Copyright © 2014 All Rights Reserved
  25. 25. In another example, the SNF provided 50 to 55 minutes of therapy a day to the beneficiary during the look-back period. It lowered the amount to 30 to 40 minutes a day during the rest of the coverage period but then raised it back to 50 to 55 minutes during the next look- back period. Harmony Healthcare International, Inc. 25 Therapy Minutes Copyright © 2014 All Rights Reserved
  26. 26. For 17 percent of claims, SNFs misreported whether the beneficiaries received special care. The inaccuracies came primarily from one MDS item in this category – intravenous medication. At the time of our review, SNFs were allowed to report intravenous medication if the beneficiary received it in the hospital prior to or during the SNF stay. Harmony Healthcare International, Inc. 26 MDS Copyright © 2014 All Rights Reserved
  27. 27. For these claims, the medical records either did not indicate that intravenous medication was provided during the hospital or SNF stay or clearly contradicted that these services were provided Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 27 MDS
  28. 28. For 7 percent of claims, SNFs misreported the amount of assistance beneficiaries needed with activities of daily living (e.g., bed mobility, transfers, eating, and toilet use) SNFs also misreported MDS items related to oral and nutritional status and items related to skin conditions and treatments Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 28 MDS
  29. 29. SNFs did not always report the correct number of stage of skin ulcers or they reported the presence of burns or open lesions inaccurately. They also did not always correctly report skin treatments, such as surgical wound care or ulcer care. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 29 Skin
  30. 30. Increase and expand reviews of SNF claims CMS should instruct its contractors to conduct more medical reviews of SNF claims Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 30 OIG Recommendations
  31. 31. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 31 OIG Recommendations Use its Fraud Prevention System to Identify SNFs that are Billing for Higher Paying RUGs CMS should use its Fraud Prevention System to identify and target these SNFs
  32. 32. Monitor Compliance with the New Therapy Assessments As of October 2011, SNFs must complete a “change of therapy” assessment when the amount of therapy provided no longer reflects the RUG and an “end of therapy” assessment when therapy is discontinued for 3 days Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 32 OIG Recommendations
  33. 33. CMS should instruct its MACs and RACs to closely monitor SNFs utilization of these assessments through analyses of claims data. Such analyses will identify SNFs that are using the assessments infrequently or not at all. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 33 OIG Recommendations
  34. 34. Change the Current Method for Determining How Much Therapy is Needed to Ensure Appropriate Payments Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 34 OIG Recommendations
  35. 35. CMS should instruct the MACs to provide education to all SNFs, as well as specific training to selected SNFs, to improve the accuracy of their MDS reporting Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 35 OIG Recommendations
  36. 36. Follow up on the SNFs That Billed in Error In a separate memorandum, we will refer to CMS for appropriate action the SNFs with claims in our sample that had inaccurate RUGs or that did not meet coverage requirements Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 36 OIG Recommendations
  37. 37. Appendix D: Sample Sizes, Point Estimates, and 95 Percent Confidence Intervals for Estimates Presented in the Report Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 37 Characteristic Sample Size Point Estimate 95 Percent Confidence Interval SNF claims in error in 2009 499 24.9% 19.9%-30.4% SNF claims with inaccurate RUGs 499 22.8% 18.0%-28.2% SNF claims with higher paying RUGs than were appropriate (upcoded) 499 20.3% 15.6%-25.6% Upcoded SNF claims that had an Ultra High RUG 101 48.2% 34.9%-61.7% Upcoded SNF claims in which SNFs reported providing more therapy on the MDS than was indicated in the medical record 101 56.8% 42.8%-70.2% Upcoded SNF claims in which reviewers determined that the amount of therapy was not reasonable and necessary 101 25.6% 14.6%-39.4% SNF claims with lower paying RUGs than were appropriate (downcoded) 499 2.5% 1.3%-4.5% SNF claims that did not meet Medicare coverage requirements 499 2.1% 0.7%-4.7% Total inappropriate Medicare payments for SNF claims 499 $1.5 billion $988 million- $2.0 billion Inappropriate Medicare payments in proportion to total payments to SNFs in 2009 499 5.6% 3.7%-7.6% Medicare payments for SNF claims with inaccurate RUGs 499 $1.2 billion $736 million- $1.6 billion SNF claims that had inaccurate information on the MDS 487 47.3% 41.2%-53.5% Source: Office of Inspector General medical record review, 2012
  38. 38. What is Skilled Care? Harmony Healthcare International, Inc. 38Copyright © 2014 All Rights Reserved
  39. 39. What is Skilled Care? Why is this material important? Which team members should be aware of the Medicare Skilled Care criteria? How often will this criteria be relevant to current beneficiaries and applicable for denied claims? Harmony Healthcare International, Inc. 39Copyright © 2014 All Rights Reserved
  40. 40. What is Skilled Care? Requires the skills of qualified technical or professional health personnel such as RN, LPN, PT, OT or SLP Must be provided directly by or under the general supervision of a licensed nurse or skilled rehab personnel to assure the safety of the resident and to achieve the medically desired result “General supervision” requires initial direction and periodic inspection of activity Ordered by a physician Services are needed and provided on a daily basis Harmony Healthcare International, Inc. 40Copyright © 2014 All Rights Reserved
  41. 41. What is Skilled Care? The need for skilled care must be justified and documented in the medical record Conditions may have prompted the initial hospitalization, but also include the conditions that arose during recovery in the SNF Harmony Healthcare International, Inc. 41Copyright © 2014 All Rights Reserved
  42. 42. Harmony Healthcare International, Inc. 42 What is Skilled Care ? Direct Skilled Nursing Services Management and Evaluation of a Care Plan Observation and Assessment Teaching and Training Skilled Rehabilitation Copyright © 2014 All Rights Reserved
  43. 43. Skilled Services Categories: Inherent Complexity Inherent Complexity – Direct skilled nursing services including: IV feeding IV meds Suctioning Tracheostomy Care Ventilator support Ulcers Harmony Healthcare International, Inc. 43Copyright © 2014 All Rights Reserved
  44. 44. Skilled Services Categories: Inherent Complexity Inherent Complexity Tube feedings Respiratory Therapy 7 days per week Surgical wound or open lesions with treatments Unstable clinically with diabetes with injections Transfusions Chemotherapy Colostomy Care, early post op care Harmony Healthcare International, Inc. 44Copyright © 2014 All Rights Reserved
  45. 45. Skilled Services Categories: Skilled Observation and Assessment Reasonable probability or possibility for complication Potential for further acute episodes Identify and Evaluate the need for modification of treatment Evaluate initiation of additional medical procedures Skilled observation can be required until the treatment regimen is essentially stabilized Harmony Healthcare International, Inc. 45Copyright © 2014 All Rights Reserved
  46. 46. Skilled Services Categories: Skilled Observation and Assessment Fever Dehydration Septicemia Pneumonia Nutritional Risk Chemotherapy Weight loss Blood sugar control Impaired cognition Severe Mood and Behavior conditions Harmony Healthcare International, Inc. 46Copyright © 2014 All Rights Reserved
  47. 47. Skilled Services Categories: Skilled Observation and Assessment Identify and outline daily skilled nursing observations and assessments Record DAILY each itemized area listed on your outline Harmony Healthcare International, Inc. 47Copyright © 2014 All Rights Reserved
  48. 48. Skilled Services Categories: Skilled Observation and Assessment Neurological Respiratory Cardiac Circulatory Pain/Sensation Nutritional Gastrointestinal Genitourinary Musculoskeletal Skin Harmony Healthcare International, Inc. 48Copyright © 2014 All Rights Reserved
  49. 49. Skilled Services Categories: Skilled Observation and Assessment A patient with arteriosclerotic heart disease with congestive heart failure requires close observation by skilled nursing personnel for signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication Skilled observation is needed to determine when the digitalis dosage should be reviewed or whether other therapeutic measures should be considered, until the patient’s treatment regimen is essentially stabilized Harmony Healthcare International, Inc. 49Copyright © 2014 All Rights Reserved
  50. 50. Skilled Services Categories: Skilled Observation and Assessment A patient has been hospitalized following a heart attack. Following treatment but before mobilization, he is transferred to the SNF. Because it is unknown whether exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated and continued until the patient’s treatment regimen is essentially stabilized Harmony Healthcare International, Inc. 50Copyright © 2014 All Rights Reserved
  51. 51. Skilled Services Categories: Skilled Observation and Assessment A frail 85-year-old man was hospitalized for pneumonia. The infection resolved, but the patient, who had previously maintained adequate nutrition, will not eat or eats poorly. The patient is transferred to a SNF for monitoring of fluid and nutrient intake and the assessment of the need for tube feeding and assisted feeding if required. Observation and monitoring by skilled nursing personnel of the patient’s oral intake is required to prevent dehydration. Harmony Healthcare International, Inc. 51Copyright © 2014 All Rights Reserved
  52. 52. Skilled Services Categories: Skilled Observation and Assessment A patient left the acute hospital on a high dosage of Coumadin with daily clotting time studies Assessment and observation is needed until a maintenance dosage is attained and the patient/resident shows no adverse symptoms. Regulation is an integral part of this patient/resident’s coverage. Ongoing observation and assessment, notifying the physician and multiple changes in the plan of care, are also skilled in nature. Harmony Healthcare International, Inc. 52Copyright © 2014 All Rights Reserved
  53. 53. Skilled Services Categories: Skilled Observation and Assessment If a patient was admitted for skilled observation but did not develop a further acute episode or complication, the skilled observation services still are covered so long as there was reasonable probability for such a complication or further acute episode “Reasonable probability” means that a potential complication or further acute episode is a likely possibility Harmony Healthcare International, Inc. 53Copyright © 2014 All Rights Reserved
  54. 54. Skilled Services Categories: Management and Evaluation of a Care Plan Based on the Physician’s orders, these services require the involvement of skilled nursing to meet the resident’s Medical needs Promote recovery Ensure medical safety Harmony Healthcare International, Inc. 54Copyright © 2014 All Rights Reserved
  55. 55. This area includes The sum total of unskilled services Potential for serious complications High probability of relapse Recovery and safety Meet medical needs Includes resident’s overall condition Harmony Healthcare International, Inc. 55 Skilled Services Categories: Management and Evaluation of a Care Plan Copyright © 2014 All Rights Reserved
  56. 56. Skilled Services Categories: Management and Evaluation of a Care Plan Topic Areas to include: Surgical sites Circulatory status Status of fractures Maintenance of weight-bearing status Skin Care Labs Consultant Recommendations Harmony Healthcare International, Inc. 56Copyright © 2014 All Rights Reserved
  57. 57. Skilled Services Categories: Management and Evaluation of a Care Plan Although any of the required services could be performed by a properly instructed person, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the nature of the patient’s condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient’s recovery and safety. The management of this plan of care requires skilled nursing personnel until the patient’s treatment regimen is essentially stabilized, even though the individual services involved are supportive in nature and not require skilled nursing personnel. Harmony Healthcare International, Inc. 57Copyright © 2014 All Rights Reserved
  58. 58. Skilled Services Categories: Management and Evaluation of a Care Plan Example: An aged patient is recovering from pneumonia, is lethargic, is disoriented, has residual chest congestion, is confined to bed as a result of his debilitated condition, and requires restraints at times To decrease the chest congestion, the physician has prescribed frequent changes in position, coughing and deep breathing. While the residual chest congestion alone would not represent a high risk factor, the patient’s immobility and confusion represent complicating factors when coupled with the chest congestion, could create high probability of a relapse. Harmony Healthcare International, Inc. 58Copyright © 2014 All Rights Reserved
  59. 59. Skilled Services Categories: Teaching and Training Teaching and Training: Activities which require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen Harmony Healthcare International, Inc. 59Copyright © 2014 All Rights Reserved
  60. 60. Skilled Services Categories: Teaching and Training Colostomy care Insulin administration Prosthesis management Catheter care G-tube feedings IV access sites Braces, splints and orthotics Wound dressings and skin treatments Medication Management Orthopedic Precautions Harmony Healthcare International, Inc. 60Copyright © 2014 All Rights Reserved
  61. 61. 61 Skilled Rehabilitation Medicare Benefit Policy Manual On a daily basis Services rendered are reasonable and necessary MD ordered Practical matter An appropriately licensed or certified individual must provide or directly supervise the therapeutic service and coordinate the intervention with nursing services Harmony Healthcare International, Inc. Copyright © 2014 All Rights Reserved
  62. 62. 62 Skilled Rehabilitation/ MD Involvement The service must be ordered by a physician. The therapy intervention must relate directly and specifically to an active written treatment regimen established by the physician after any needed consultation with the qualified rehabilitation therapy professional and must be reasonable and necessary to the treatment of the beneficiary’s illness or injury necessary to the treatment of the beneficiary’s illness or injury Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  63. 63. 63 Skilled Rehabilitation/ MD Involvement MD involvement to prevent injuries Medicare allows the professional therapist to develop a suggested plan of treatment and to begin providing services based on the plan prior to MD signature MD signature required before facility bills Medicare MD Faxed signatures acceptable Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  64. 64. 64 Skilled Rehabilitation Overview Directly related to a written plan of treatment Requires knowledge/skills/judgment of qualified professional Services must be considered under acceptable standards clinical practice Expectation of improvement of restorative potential in a reasonable and predictable period of time….or…. Establishment of a safe and effective maintenance program Harmony Healthcare International, Inc. Copyright © 2014 All Rights Reserved
  65. 65. 65 Basic Criteria for Rehabilitation Services Must be specifically related to the Physician’s Treatment Plan Skill of a qualified therapist must be needed Treatment plan must expect the patient to improve Services must fall within accepted standards of medical practice and be specific to the patient The services must be reasonable and necessary Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  66. 66. PEPPER Program for Evaluating Payment Patterns Electronic Report Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 66
  67. 67. PEPPER Compares SNFs to other SNFs nationally 2013 Report was received via mail on or about August 30, 2013 Envelope with red print on the outside containing your facility specific PEPPER Perceived as Junk mail Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 67
  68. 68. Outliers and the Evolution of PEPPER CMS sees high Medicare expenses as suggestive of over coding CMS asserts 20% highest expenses are questionable CMS identifies expenses above the 80th percentile as outliers CMS asserts that the Bottom 20% of outliers are under coding The bottom 20th percentile as outliers could be perceived as evidence of poor Quality of Care Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 68
  69. 69. PEPPER Data Compare Targets Report Target Area Reports SNF Top RUGs Reports Jurisdiction-wide Top RUGs Reports Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 69
  70. 70. PEPPER Data PEPPER is a Microsoft Excel workbook that can be opened and saved to a PC Per TMF; the report is not intended for use on a network but may be saved to as many PCs as necessary Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 70
  71. 71. Where is My PEPPER? From TMF Health Quality Institute PEPPERResources.org from the PEPPER HELP Desk http://pepperresources.org/HelpContactUs.aspx Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 71
  72. 72. Where is My PEPPER? Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 72
  73. 73. PEPPER Resources Scroll Down Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 73
  74. 74. Skilled Nursing Facility Distribution Schedule TMF will distribute PEPPER according to the schedule and methods below. Annually, on or about May 5 through May 12, 2014 SNFs/swingbeds that are part of a short-term acute care hospital Electronically via QualityNet secure file exchange Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 74
  75. 75. Skilled Nursing Facility Distribution Schedule Free-standing SNFs and SNFs that are part of another type of hospital Available electronically to the SNF’s CEO, president or administrator via secure portal on PEPPERresources.org Note: SNFs that are part of a critical access hospital will not receive PEPPER. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 75
  76. 76. PEPPER Resources Resource Manual Navigate through PEPPER by clicking on the worksheet tabs at the bottom of the screen Each tab is labeled to identify the contents of each worksheet (e.g., Target Area Reports, Compare Targets Report) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 76
  77. 77. Where is My PEPPER? Effective January 1, 2014 TMF will no longer resend copies of SNF PEPPERs (version Q4FY12) which were initially mailed to all SNFs on August 30, 2013 The next SNF PEPPER (version Q4FY13) will be distributed in late April-early May 2014 and will be available for access in electronic format by the SNF’s CEO/administrator/president. TMF will send an email notification when the Q4FY13 SNF PEPPERs are available TMF encourages you to sign up to receive this email by visiting the Home page of PEPPERresources.org and click on the gray box in the upper right area of the page to “Join the email list….”; fill out the requested information and select the “Skilled Nursing Facility”. This will ensure that you receive any future information/updates pertaining to the SNF PEPPER. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 77
  78. 78. PEPPER Provider-specific Medicare data statistics for services vulnerable to improper payments Compares to all other SNFs across the state, nation or Medicare Audit Contractors(MAC) jurisdiction Shared with both Medicare Audit Contractors (MACs) and the Medicare Recovery Auditor Contractors (RACs) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 78
  79. 79. PEPPER Targeted areas were derived from two recent Office of Inspector General (OIG) Reports: “Inappropriate Payments to skilled Nursing Facilities Cost Medicare than a Billion Dollars in 2009” (November 2012) “Questionable Billing by Skilled Nursing Facilities” (December 2010) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 79
  80. 80. Claims Data The SNF PEPPER provides SNFs with their jurisdiction, state and national percentile values for each target area with reportable data for the most recent three fiscal years When the target (numerator) count is less than 11 for a target area for a time period, statistics are not displayed Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 80
  81. 81. Target Areas Therapy RUGs with High ADLs Non-therapy RUGs with High ADLs Change of Therapy Assessment Ultra High RUGs Therapy RUGs 90+ Day Episodes of Care Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 81
  82. 82. Compare Targets Report Each SNF PEPPER summarizes claims data statistics (obtained from paid SNF Medicare UB-04 claims) for SNF episodes of care that end in the most recent three federal fiscal years (the federal fiscal year spans October 1 through September 30) A SNF is compared to other SNFs in three comparison groups: Nation Medicare Administrative Contractor (MAC) jurisdiction and MAC state. These comparisons enable a SNF to determine if its results differ from other SNFs and if it is at risk for improper Medicare payments (i.e., is an “outlier”) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 82
  83. 83. Compare Targets Report Jurisdiction JE Noridian Healthcare Solutions – 1462 facilities JF Noridian Healthcare Solutions – 775 J5 Wisconsin Physician Services – 2730 J6 National Government Services – 1402 JH Novitas Solutions, Inc. – 2454 J8 Wisconsin Physician Services – 591 J9 First Coast Service Options – 433 J10 Cahaba GBA – 761 All Jurisdictions – 15,660 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 83
  84. 84. Compare Targets Report Page 1 (after introduction) FY2012 only When the SNF’s percent is at or above the national 80th percentile for a target area, the SNF’s percent is printed in red bold When the SNF’s percent is at or below the national 20th percentile for a target area the SNF percent is printed in green italics When the SNF is not an outlier, the SNF’s percent is printed in black Blank if Less than 11 SNFs or episodes in group Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 84
  85. 85. Each Target Area listed in the report contains a Comparative Data Table. Identifies the target area percents that are at the 80th and 20th percentiles (for areas at risk for under coding only) for the three comparison groups of nation, jurisdiction and state. The percent values are graphed as trend lines on the Target Area Graph. State percentiles are zero when there are fewer than 11 SNFs with reportable data for the target area in the state. Jurisdiction percentiles are zero when there are fewer than 11 SNFs with reportable data for the target area in the jurisdiction. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 85 Comparative Data Table
  86. 86. Target Area Reports PEPPER Target Area Reports display a variety of statistics for each target area summarized over three years. Each report includes Target area graph Target area data table Comparative data Interpretive guidance Suggested interventions Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 86
  87. 87. PEPPER Resources Resource Manual Suggested interventions if at/above 80th percentile ADLs This could indicate a risk of potential overcoding of beneficiaries’ activities of daily living (ADL) status. The SNF should determine whether the amount of assistance beneficiaries need with ADL as reported on the MDS is supported and consistent with medical record documentation. Change of Therapy This could indicate that the SNF is experiencing challenges with delivering services to the beneficiary as anticipated. The SNF may look into factors that lead to the need for the COT assessment (e.g., can care planning be improved? Are there issues with completing therapy as scheduled?) Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 87
  88. 88. PEPPER Resources Resource Manual Suggested interventions if at/above 80th percentile Ultra High and Therapy RUGs This could indicate that the SNF is improperly billing for therapy services. The SNF should determine whether therapy provided was reasonable and medically necessary, and that the amount of therapy reported on the MDS is supported by documentation in the medical record. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 88
  89. 89. ADLs Therapy RUG (2011) RUX Rehabilitation Ultra High / Extensive Services ADL 11 – 16 RVX Rehabilitation Very High / Extensive Services ADL 11 – 16 RHX Rehabilitation High / Extensive Services ADL 11 – 16 RMX Rehabilitation Medium / Extensive Services ADL 11 - 16 RLX Rehabilitation Low / Extensive Services ADL 2 – 16 RUC Rehabilitation Ultra High with ADL 11 - 16 RVC Rehabilitation Very High ADL 11 - 16 RHC Rehabilitation High ADL 11 – 16 RMC Rehabilitation Medium ADL 11 – 16 RLB Rehabilitation Low ADL 11 – 16 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 89
  90. 90. ADLs Non-Therapy RUG (2011) ES3 Extensive Services Tracheostomy Care and Ventilator/respirator ADL 2 - 16 ES2 Extensive Services Tracheostomy Care or Ventilator/respirator ADL 2 - 16 ES1 Extensive Services Infection Isolation without Tracheostomy Care or Ventilator/respirator and ADL 2 – 16 HE2 Special Care High with Depression ADL 15 – 16 HE1 Special Care High with No Depression and ADL 15 – 16 LE2 Special Care Low with Depression ADL 15 – 16 LE1 Special Care Low with No Depression ADL 15 – 16 CE2 Clinically Complex with Depression ADL 15 – 16 CE1 Clinically Complex with No Depression ADL 15 – 16 PE2 Physical Function with ≥2 Restorative Nursing ADL 15 – 16 PE1 Physical Function with ≤1 Restorative Nursing ADL 15 – 16 Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 90
  91. 91. PEPPER Resources Resource Manual Suggested interventions if at/above 80th percentile 90+ Day Episodes of Care This could indicate that the SNF is continuing treatment beyond the point where those services are necessary. The SNF should review documentation for beneficiary episodes of care with a length of stay of 90+ days to ensure that beneficiaries’ continued care is appropriate and that they received a skilled level of care. The SNF should review plans of care for appropriateness and assess appropriateness of discharge plans. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 91
  92. 92. PEPPER Resources Resource Manual Suggested interventions if at/below 20th percentile ADLs This could indicate a risk of potential undercoding of beneficiaries’ADL status. The SNF should determine whether the amount of assistance beneficiaries need with ADL as reported on the MDS is supported and consistent with medical record documentation. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 92
  93. 93. PEPPER Resources Resource Manual Suggested interventions if at/below 20th percentile Change of Therapy SNFs that are using the COT assessment infrequently or not at all may be targeted by MACs or RACs for review to establish whether therapy assessments are being completed as required (see https://oig.hhs.gov/oei/reports/oei-02-09-00200.asp page 15). Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 93
  94. 94. PEPPER Resources Resource Manual Suggested interventions if at/below 20th percentile Ultra High and Therapy RUGs Not Applicable 90+ Day Episodes of Care Not Applicable Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 94
  95. 95. HHI Analysis Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 95
  96. 96. HHI Comparative Data Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 96
  97. 97. Are You Ready for the SNF PEPPER? Why is Data Collection and Analysis a MUST? Harmony Healthcare International, Inc. 97Copyright © 2014 All Rights Reserved
  98. 98. Are You Ready for the SNF PEPPER? Compliance, Compliance Compliance Harmony Healthcare International, Inc. 98Copyright © 2014 All Rights Reserved
  99. 99. Are You Ready for the SNF PEPPER? Per CMS The Office of Inspector General encourages SNFs to develop and implement a compliance program to protect their operations from fraud and abuse Beginning in 2013, SNFs are required to have a compliance program As part of a compliance program, a SNF should conduct regular audits to ensure services provided are necessary and that charges for Medicare services are correctly documented and billed The Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide the SNF’s auditing and monitoring activities Harmony Healthcare International, Inc. 99Copyright © 2014 All Rights Reserved
  100. 100. Compliance Program Per Federal and State laws and Federal healthcare program requirements A system of policies and procedures Monitoring and Auditing tools Communication and reporting methods Enforcement Leadership Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 100
  101. 101. OIG Supplemental Guidance: “Compliance programs help nursing facilities fulfill their legal duty to provide quality care; to refrain from submitting false or inaccurate claims or cost information to the Federal health care programs; and to avoid engaging in other illegal practices” Harmony Healthcare International, Inc. 101 Compliance and Ethics Program Copyright © 2014 All Rights Reserved
  102. 102. OIG Guidance http://oig/hhs/gov/compliance/complianc eguidance/index.asp Harmony Healthcare International, Inc. 102 Be As Informed As Possible Copyright © 2014 All Rights Reserved
  103. 103. Compliance Is Mandatory Medicare/Medicaid Condition of Participation March 23, 2013 Patient Protection and Affordable Care Act Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 103
  104. 104. HIPAA Privacy Rule Security Rule Breach Notification Rule Copyright © 2014 All Rights Reserved 104Harmony Healthcare International, Inc.
  105. 105. Penalties: HIPAA Civil penalties: up to $50,000 per violation ($1.5 Million annual maximum per type of violation) Criminal penalties: Up to $250,000 and 10 years imprisonment Copyright © 2014 All Rights Reserved 105Harmony Healthcare International, Inc.
  106. 106. Efficacy Criminal sanctions may be mitigated by a compliance program, but only if that program is effective Most SNFs lack the policies & procedures, staff training, audit functions, and regulatory updates to keep their compliance programs effective 106Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  107. 107. Required Compliance Program Components Written Policies & Procedures, Code of Conduct Compliance Officer & Compliance Committee Training and Education Effective Lines of Communication Enforcement of Standards Responding Promptly to Detected Offenses and Taking Corrective Action Auditing and Monitoring 107Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  108. 108. Risk Areas Quality of Care Resident Rights Billing & Claims Submission Employee Screening Kickbacks, Inducements and Self-Referrals Cost Reporting HIPAA Privacy and Security Record Creation and Retention Anti-Supplementation Medicare Part D 108Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  109. 109. Baseline Audit Identify risk areas Identify strengths and weaknesses Seek input from all departments Always be on the lookout for “new” risks 109Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  110. 110. Periodic Audits Quality of Care Resident Rights Billing & Cost Reporting Employee Screening Kickbacks, Inducements and Self-Referrals Submission of Accurate Claims HIPAA Privacy and Security Record Creation and Retention Anti-Supplementation Medicare Part D Additional risk areas identified in the baseline audit 110Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  111. 111. Annual Review Annual Review of the overall effectiveness of the compliance program 111Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  112. 112. Compliance Officer Develop a position description Essential duties Oversee and monitor the implementation of a corporate compliance program Help the organization, through policies and procedures, auditing, and training, minimize the risk of fraud and abuse 112Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  113. 113. Compliance Officer Reports to the Compliance Committee Directs facility audits Collect data Develop responsive action plans Manages compliance hotline reports Compliance training for the organization Harmony Healthcare International, Inc. 113Copyright © 2014 All Rights Reserved
  114. 114. Compliance Officer Manage employee, officer, contractor, and volunteer screening Oversee HIPAA compliance activity Participate in the Quality Assurance program Conduct annual compliance program review and update Ensure contractors are aware of your compliance program and resident rights 114Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  115. 115. Compliance Officer A Compliance Officer can hold another position within the organization at the same time, i.e., staff development coordinator, quality assurance nurse Requires a dynamic person will have to interact with Board members, CNAs, housekeepers, department leaders, contractors, volunteers, and regulators 115Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  116. 116. Compliance Programs Train and educate Provide compliance training to all employees, officers, directors, owners upon hire and annually Create a training schedule for each risk area 116Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  117. 117. Compliance Programs Audit and Monitor Develop audit tools for each risk area Schedule audits throughout the year Assign responsibility for audits Develop a reporting mechanism for audit results 117Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  118. 118. Compliance Programs Review annually Acknowledge progress Identify areas to further advance compliance 118Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  119. 119. Compliance Programs Stay current Monitor and incorporate updates into the Compliance Program New regulations OIG updates Recent enforcement actions 119Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  120. 120. Compliance Programs Compliance Officer is the key to a successful program 120Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved
  121. 121. Closing Thoughts There is no “Good” or “Bad” PEPPER Compliance chart auditing at regular intervals for outlier areas Analyze PEPPER data Develop a Compliance Program Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 121
  122. 122. Conclusion Educate, Discuss and Prepare Communicate to all Staff Medicare Skilled Care Criteria Conduct internal/external Mock Audits to educate staff Refine Interdisciplinary Management of Medicare Additional Documentation Requests Harmony Healthcare International, Inc. 122Copyright © 2014 All Rights Reserved
  123. 123. Questions/Answers Harmony Healthcare International (978) 887 - 8919 www.Harmony-Healthcare.com Connect with Us! @ElisaBovee @Harmonyhlthcare facebook.com/HarmonyHealthcareInternational H linkedin.com/company/harmony-healthcare 123Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc.
  124. 124. Follow-up PEPPER Webinar… Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. Interpreting Your 2014 SNF PEPPER May 9, 2014: 1pm-2:30pm (EST) Speakers: Kris Mastrangelo , OTR/L, LNHA, MBA & Keri Hart, MS-CCC/SLP, RAC-CT, CHHRP-QT 124 Now that you are ready for your SNF PEPPER, learn how to interpret it during our special follow-up webinar Register Online: https://www.eventbrite.com/e/interpreting-your- 2014-pepper-webinar-tickets-11244501607
  125. 125. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 125 Register online http://info.harmony-healthcare.com/harmony2014 or by phone (978) 887-8919 ext. 13 Register Online
  126. 126. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Assess your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 126
  127. 127. Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 127
  128. 128. Compare Targets Report SNFs can use the Compare Targets Report to help prioritize areas for auditing and monitoring The Compare Targets Report includes all target areas with reportable data for the most recent year included in PEPPER For each target area, the Compare Targets Report displays the SNF’s number of target (numerator) count, Target area percent SNF’s percentiles as compared to the nation, jurisdiction and state comparison groups Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 128

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