atx21 keynote - "can pepper help cover your assets?"

Program for Evaluating PaymentPatterns Electronic Report

Can PEPPER Help Cover Your Assets?

Kimberly HrehorNovember 5, 2013


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Compliance Program Elements:1. Compliance policies & procedures, standards of conduct2. Compliance office & compliance committee3. Open lines of communication4. Training & teaching

5. Monitoring & auditing6. Response to detected deficiencies7. Enforcement of disciplinary standards

This is where PEPPER can help!


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


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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!


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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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-02-09-00200.pdf

http://oig.hhs.gov/oei/reports/oei-02-09-00200.pdf

http://oig.hhs.gov/oei/reports/oei-02-09-00200.pdf


SNF PEPPER Target AreasTarget Area 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, RLBD: count of days billed for all therapy RUGs

Nontherapy RUGs with High ADLs

N: count of days billed with RUG equal to SSC, CC2, CC1, BB2, BB1, PE2, PE1, IB2, IB1 in RUG III; HE2, HE1, LE2, LE1, CE2, CE1, BB2, BB1, PE2, PE1 in RUG IVD: count of days billed for all nontherapy RUGs

Change of Therapy Assessment

N: count of assessments with AI second digit “D” D: count of all assessments

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Coding of ADLs


SNF PEPPER Target Areas, cont.

Target Area Target Area Definition

Ultrahigh Therapy RUGs

N: count of days billed with RUG equal to RUX, RUL, RUC, RUB, RUAD: count of days billed for all therapy RUGs

Therapy RUGs

N: count of days billed for all therapy RUGsD: count of days billed for all therapy and nontherapy RUGs

90+ Day Episodes of Care

N: count of episodes of care at the SNF with LOS 90+ days D: count of all episodes of care at the SNF

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Therapy


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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 necessary10


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SNF PEPPERsMailed Aug. 30, 2013– Check internally for

envelopePEPPERresources.org– SNF PEPPER user’s guide– Recorded training sessions– Help Desk– Sample SNF PEPPER– Other resources


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Future PEPPER PlansNext release planned for May 2014Will summarize statistics for FYs 2011, 2012,

2013Any updates will be communicated through

our listserv, CMS, national/state associations

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