The New P.E.P.P.E.R. Reports: Understanding The Data & Risk

1. The New P.E.P.P.E.R.Reports: Understanding The Data & Risk

2. What is P.E.P.P.E.R.? • Program for Evaluating Payment Patterns Electronic Report (PEPPER) contains one SNF’s Medicare claims data statistics for areas that may be at risk for improper Medicare payments. • PEPPER compares a SNF’s Medicare data with aggregate Medicare data for the state, MAC jurisdiction and nation.

3. What is P.E.P.P.E.R.? • PEPPER is available for short-term (ST) and long-term (LT) acute care PPS hospitals, critical access hospitals (CAHs), inpatient psychiatric facilities (IPFs), inpatient rehabilitation facilities (IRFs), partial hospitalization programs (PHPs) and hospices. • SNF PEPPERs will be released by August 30, 2013

4. 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 an educational tool that is intended to help providers assess their risk for improper Medicare payments.

5. PEPPER Summarizes Medicare Data • Paid Medicare claims (UB-04) - SNF/swing bed final action claims • SNFs, swing beds operated by short- and long-term acute care hospitals and inpatient rehabilitation facilities (CAH swing beds are not included) • Services provided during the report time period • Medicare claim payment amount >$0 (includes Medicare secondary payer claims) • Exclude HMO claims • Exclude canceled claims

6. PEPPER Data • Organized in three 12-month time periods based on fiscal year (FY). • Q4FY12 release contains statistics for SNF episodes of care at the SNF that end between Oct. 1, 2010 through Sept. 20, 2013 (fiscal years 2011, 2012 and 2013)

7. PEPPER Target Area Statistics • PEPPER reports on services provided to a beneficiary whose SNF episode of care ends during the respective fiscal year. • An episode of care is created from the claims submitted by a SNF for each beneficiary.

8. What is an “Episode of Care” • To create an EOC: All claims submitted by a SNF for a beneficiary are collected and sorted from the earliest “Claim From” date to the latest. • If the patient discharge status code on the latest claim in a series indicates that the beneficiary was discharged or did not return for continued care, that beneficiary’s EOC is included in the time period in which the latest “Through Date” falls. • If there is a gap between one claim’s “Through Date” to the next claim’s “From Date” of more than 30 days, then that is considered the ending of one EOC and the beginning of a new EOC. • If the latest claim in the series ends in the last month of the latest time period (Sept. 1-30, 2013 for the Q4FY13release) and indicates that the beneficiary was still a patient (patient discharge status code “30”), then that beneficiary’s EOC is not included. • Each EOC is included in the time period in which the latest “Through Date” falls. • Claims are collected for four months prior to each time period so that the longer lengths of stay may be evaluated.

9. SNF Improper Payment Risks • PEPPER does not identify improper payments. • SNFs are reimbursed through the SNF prospective payment system (PPS). • Minimum Data Set (MDS) • Resource Utilization Group (RUG) • Visit CMS SNF PPS page for more information: • http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/

10. SNF Improper Payment Risks, cont. • SNFs can be at risk for improper Medicare payments. • Target areas were identified based on a review of literature regarding SNF payment vulnerabilities, review of the SNF PPs, analysis of claims data and coordination with CMS subject matter experts.

11. Office of Inspector General Report • “Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More than a Billion Dollars in 2209”, November 2012, OEI-02-09-00200 • Identified 25% of SNF claims billed in error • Available at http://oig.hhs.gov/oei/reports/oei-02-09-00200.pdf

12. Target Area • Area identified as potentially at risk for improper Medicare payments. • Constructed as a ratio: • Numerator = RUG days/episodes of care identified as potentially problematic • Denominator = larger reference group that contains

13. SNF Target Areas

14. 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

15. 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 IV • D: count of days billed for all therapy RUGs

16. Change of Therapy Assessment • N: Count of assessments with AI second digit “D” • D: count of all assessments

17. 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

18. Therapy RUGs • N: count of days billed for all therapy RUGs • D: count of days billed for all therapy and nontherapy RUGs

19. 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

20. Three Basic Statistics • Count of RUG days/episodes of care (numerator and denominator) • Payments (sum and average) - Only available for the “90 + Days EOC” target area • Average length of stay (ALOS) - Not available for the “COT Assessment” target area

21. Percents and Percentiles • Percents and percentiles are at the heart of PEPPER. • It is easy to confuse these terms. • Let’s clarify the definitions and how they relate to each other in PEPPER.

22. Target Area Statistics • Numerator- count of RUG days/episodes of care meeting the numerator definition; will not display if <11 • Denominator – count of RUG days/episodes of care meeting the denominator definition; will not display if <11

23. Target Area Percents • Target area percents are calculated by dividing the numerator count by the denominator count for each SNF for ach time period, then multiplying by 100. • Example: 90+ Day episodes of care: 13 episodes of care with 90+ days at the SNF 25 episodes of care at the SNF X 100=52%

24. Percentiles • The target area percent lets the SNF know its billing patterns. • More useful information comes from knowing how it compares to other SNFs, which is why we calculate percentiles. • Definition of a percentile: • The percentage of SNFswith a lower target area percent

25. Percentiles, cont. • To calculate percentiles for all SNFs in a comparison group (nation, jurisdiction or state), all SNFs’ target area percents are sorted from largest to smallest for each time period. • Example: • If 40 percent of the SNFs’ target area percents were lower than SNF A, then SNF A would be at the 40th percentile.

26. Comparisons in PEPPER • PEPPER provides state, MAC/FI jurisdiction and national comparisons.

27. About the MAC/FI Jurisdiction • The MAC/FI jurisdiction in PEPPER closely corresponds to current CMS MAC jurisdictions (see next slide). • These jurisdictions are evolving as the transition from legacy Part A FIsto the MACs progresses.

29. Review: How does PEPPER identify SNFs at Risk? • A SNF’s target area percent is compared to other SNFs’ percents in the state, MAC/FI jurisdiction and nation. • If the SNF’s target area percent is at/above the national 80th percentile or at/below the national 20th percentile, the SNF is identified as at risk for improper Medicare payments. • Compare and Target Area reports: • Red bold print - at or above the national 80th percentile for the target area. • Green italic print - at or below the national 20th percentile for the target area (areas at risk for undercoding only)

30. SNF Top RUGs Reports • List the top RUGs by number of days billed for EOC that end in FY 2012. • Include number of RUG days billed, percent of RUG days to total days, percent of EOC with the RUG billed to total days, percent of EOC with the RUG billed to total EOC, SNF’s ALOS for RUG. • Supplemental reports have no impact on outlier status or risk for improper payments. • Two reports: • Top RUGs for all EOC • Top RUGs for EOV with 90+ days

31. Jurisdiction Top RUGs Reports • List the top RUGs by number of days billed for EOC that end in FY 2012 for all SNFs in the jurisdiction. • Include same data elements as the SNF-specific report. • Two reports: • Top RUGs for all EOC in the jurisdiction • Top RUGs for all EOC with 90+ days in the jurisdiction

32. SNF PEPPER Demonstration

33. How to Use and Obtain PEPPER and Helpful Resources

34. How to Prioritize PEPPER Findings • Use the Compare report. • Consider percentiles as compared to: • Nation • Jurisdiction • State • Consider “Target Count”

35. SNF PEPPER User’s Guide • Complete documentation of statistics included, with target area definitions. • Includes guidance on how to use PEPPER and how to interpret PEPPER findings. • Available at PEPPERresources.org in the “SNF” section.

36. Using PEPPER • Compliance-can guide audits for areas at risk. • Audit results used to develop specific action plans for ensuring compliant documentation, providing education. • Consider patient population, external factors.

37. National-level Data • National-level data for all SNFs in that nation for the target areas will be made available at PEPPERresources.org on the “Data” page (numerator/denominator counts, average length of stay, total payments (where available)). • An additional report shows percentiles for hospital-based SNFs and all other SNFs.

38. How is SNF PEPPER distributed? • SNFs that are free-standing or part of a provider other than a short-term acute care hospital: Distributed in hard copy format via Electronic Reports and Directions • http://pepperresources.com/PEPPER/SecurePEPPERAccess.aspx • SNF s that are part of a short-term acute care hospital: Distributed via My QualityNet to the STACH QualityNet Administrators and those with basic user accounts and the PEPPER recipient role. • TMF plans to distribute the SNF PEPPER annually.

39. Now what? • Refer to the user’s guide. • Share internally. • Guide auditing and monitoring. • Look for increases or decreases over time. • Identify root causes of increases or decreases. • Review medical records. • Be proactive and preventive. • Avoid “pay and chase.”

40. Who has Access to PEPPER? • PEPPER is only available to the individual SNF. • PEPPER is not publicly available, cannot be released to consultants, etc. • TMF does not send PEPPERs to MACs/Recovery Auditors, but does provide them with an Access database that contains the PEPPER statistics for SNFs in their jurisdiction/region.

41. For assistance with PEPPER: • Visit PEPPERresources.org for the PEPPER User’s Guide and training materials. • If you have questions or are in need of individual assistance, click on “Help/Contact Us,” and submit your request through the Help Desk. Complete the form, and a TMF staff member will respond promptly to assist you. • Please do not contact your state QIO for assistance with PEPPER.