1. Program for Evaluating Payment
Patterns Electronic Report
Can PEPPER Help Cover Your
Assets?
Kimberly Hrehor
November 5, 2013

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
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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.
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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!
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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.
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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
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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
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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
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9. Program for Evaluating Payment
Patterns Electronic Report
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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
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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
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12. Program for Evaluating Payment
Patterns Electronic Report
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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
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