Using the Hospice PEPPER to Support Auditing and Monitoring Efforts: Session 1

Transcription

1 Using the Hospice PEPPER to Support Auditing and Monitoring Efforts: Session 1 March, 2016 Kimberly Hrehor

2 Agenda Session 1: History and basics of PEPPER PEPPER target areas Percents and percentiles Comparison groups Session 2: PEPPER demonstration Session 3: How to use and obtain PEPPER Resources and assistance 2

3 Objective: To help you understand PEPPER so that you can use this tool, provided at no cost by the Centers for Medicare & Medicaid Services (CMS), to support auditing and monitoring efforts with the goal of ensuring compliance with Medicare regulations and preventing improper Medicare payments. 3

4 What is PEPPER? Program for Evaluating Payment Patterns Electronic Report (PEPPER) summarizes Medicare claims data statistics for one hospice in areas ( target areas ) that may be at risk for improper Medicare payments. PEPPER compares a hospice s Medicare claims data statistics with aggregate Medicare data for the nation, MAC jurisdiction and state. 4

5 History of PEPPER PEPPER was originally developed in 2003 for short-term acute care PPS hospitals. PEPPER has also been developed for long-term (LT) acute care PPS hospitals, critical access hospitals (CAHs), inpatient psychiatric facilities (IPFs), inpatient rehabilitation facilities (IRFs), partial hospitalization programs (PHPs), hospices, skilled nursing facilities (SNFs) and home health agencies (HHAs). 5

6 Why are Hospices 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. 6

7 PEPPER Summarizes Medicare Data Paid Medicare claims (UB-04) Hospice final action claims Medicare claim payment amount > zero (note: includes Medicare secondary payer claims) Exclude HMO claims Exclude canceled claims 7

8 PEPPER Data Organized in three 12-month time periods based on fiscal year (FY). FY 2013 FY 2014 FY 2015 Q4FY15 release contains statistics for hospice episodes of service/claims that end between Oct. 1, 2012 through Sept. 30, 2015 (fiscal years 2013, 2014 and 2015). 8

9 PEPPER Data Restriction Due to CMS data restrictions, the Hospice PEPPER will not display statistics when the numerator or denominator count is less than 11 for a target area in any time period. Some hospices may not see any data for some target areas or time periods. About 300 hospices will not have a PEPPER available. 9

10 PEPPER Target Area Statistics Some target areas are claims-based and summarize statistics for claims that end in the respective fiscal year. Some target areas report on services provided to a beneficiary whose episode of service ends during the respective fiscal year. An episode of service is created from the claims submitted by a hospice for each beneficiary. 10

11 What is an Episode of Service (EOS)? To create an EOS: All claims submitted by a hospice 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 (by death or alive) or did not return for continued care, that beneficiary s EOS 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 60 days, then that is considered the end of one EOS and the beginning of a new EOS. If the latest claim in the series ends in the last month of the latest time period (Sept. 1-30, 2015 for the Q4FY15 release) and indicates that the beneficiary was still a patient (patient discharge status code 30 ), then that beneficiary s EOS is not included. Each EOS is included in the time period in which the latest Through Date falls. Claims are collected for two years prior to each time period so that longer lengths of stay may be evaluated. 11

12 Bene Claim From Date Through Day Count EOS Examples for a Hospice Number Date per claim Days Btwn Claims Hospice EOS Bene A 1 8/8/2013 8/31/ n/a 1 Bene A 2 9/1/2013 9/30/ Bene A 3 10/1/ /31/ Bene A 4 11/1/ /30/ Bene A 5 12/1/ /31/ Bene A 6 1/1/2014 1/31/ Bene A 7 2/1/2014 2/29/ Bene A 8 3/1/2014 3/31/ Bene A 9 4/1/2014 4/3/ Bene A 10 10/16/ /31/ Bene A 11 11/1/ /30/ Bene A 12 12/1/ /31/ Bene A 13 1/1/2015 1/31/ Bene A 14 2/1/2015 2/12/

13 Hospice Improper Payment Risks PEPPER does not identify improper payments. Hospices are reimbursed through the Medicare Hospice Benefit (MHB). Hospices can be at risk for inappropriate beneficiary enrollment in the MHB. Target areas were identified based on review of the MHB, analysis of claims data and coordination with CMS subject matter experts. 13

14 Office of Inspector General Report Medicare Hospices Have Financial Incentives to Provide Care in Assisted Living Facilities, January 2015, OEI Available at pdf 14

15 Target Area Area identified as potentially at risk for improper Medicare payments. Constructed as a ratio: Numerator = count of claims/episodes identified as potentially problematic. Denominator = larger reference group that contains the numerator. 15

16 Hospice PEPPER Target Areas Target Area Live Discharges No Longer Terminally Ill Target Area Definition Numerator (N): count of beneficiary episodes who were discharged alive by the hospice (patient discharge status code not equal to 40, 41 or 42, excluding: beneficiary transfers (patient discharge status code 50 or 51); beneficiary revocations (occurrence code 42); beneficiaries discharged for cause (condition code H2); beneficiaries who moved out of the service area (condition code 52) Denominator (D): count of all beneficiary episodes discharged (by death or alive) by the hospice during the report period (obtained by considering all claims billed for a beneficiary by that hospice) 16

17 Hospice PEPPER Target Areas, 2 Target Area Live Discharges Revocations *new in Q4FY15 release Target Area Definition N: count of beneficiary episodes who were discharged alive by the hospice (patient discharge status code not equal to 40 (expired at home), 41 (expired in a medical facility) or 42 (expired place unknown)), with occurrence code 42 D: count of all beneficiary episodes discharged (by death or alive) by the hospice during the report period (obtained by considering all claims billed for a beneficiary by that hospice) 17

18 Hospice PEPPER Target Areas, 3 Target Area Live Discharges with LOS Days *new in Q4FY15 release Target Area Definition N: count of beneficiary episodes who were discharged alive by the hospice (patient discharge status code not equal to 40 (expired at home), 41 (expired in a medical facility) or 42 (expired place unknown)), with a length of stay (LOS) of days D: count of all beneficiary episodes discharged alive by the hospice during the report period (obtained by considering all claims billed for a beneficiary by that hospice) 18

19 Hospice PEPPER Target Areas, 4 Target Area Long Length of Stay Target Area Definition N: count of beneficiary episodes discharged (by death or alive) by the hospice during the report period whose combined days of service at the hospice is greater than 180 days (obtained by considering all claims billed for a beneficiary by that hospice) D: count of all beneficiary episodes discharged (by death or alive) by the hospice during the report period 19

20 Hospice PEPPER Target Areas, 5 Target Area Continuous Home Care Provided in an Assisted Living Facility Target Area Definition N: count of beneficiary episodes discharged (by death or alive) by the hospice during the report period where at least eight hours of Continuous Home Care (revenue code = 0652) were provided while the beneficiary resided in an Assisted Living Facility (HCPCS code = Q5002) D:count of all beneficiary episodes ending in the report period that indicate the beneficiary resided in an assisted living facility (HCPCS code = Q5002) for any portion of the episode 20

21 Hospice PEPPER Target Areas, 6 Target Area Routine Home Care Provided in an Assisted Living Facility Target Area Definition N: count of Routine Home Care days (revenue code = 0651) provided on claims ending in the report period that indicate the beneficiary resided in an assisted living facility (HCPCS code = Q5002) D: count of all Routine Home Care days (revenue code = 0651) provided by the hospice on claims ending in the report period 21

22 Hospice PEPPER Target Areas, 7 Target Area Routine Home Care Provided in a Nursing Facility Target Area Definition N: count of Routine Home Care days (revenue code = 0651) provided on claims ending in the report period that indicate the beneficiary resided in a nursing facility (HCPCS code = Q5003) D: count of all Routine Home Care days (revenue code = 0651) provided by the hospice on claims ending in the report period 22

23 Hospice PEPPER Target Areas, 8 Target Area Routine Home Care Provided in a Skilled Nursing Facility Target Area Definition N: count of Routine Home Care days (revenue code = 0651) provided on claims ending in the report period that indicate the beneficiary resided in a skilled nursing facility (HCPCS code = Q5004) D: count of all Routine Home Care days (revenue code = 0651) provided by the hospice on claims ending in the report period 23

24 Hospice PEPPER Target Areas, 9 Target Area Claims with Single Diagnosis Coded *new in Q4FY15 release No General Inpatient Care or Continuous Home Care *new in Q4FY15 release Target Area Definition N: count of claims ending in the report period that have only one diagnosis coded D: count of all claims ending in the report period with one or more diagnoses coded N: count of beneficiary episodes ending in the report period that had no amount of general inpatient care (revenue code = 0656) or continuous home care (revenue code = 0652) D: count of all beneficiary episodes ending in the report period 24

25 Three Basic Statistics Count of episodes or claims (numerator and denominator) Payments (sum and average, where calculated) Average length of stay (numerator and denominator, where calculated) 25

26 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. 26

27 Target Area Statistics Numerator number of episodes/claims/days meeting numerator definition; will not display if <11 Denominator number of episodes/claims/days meeting denominator definition; will not display if <11 27

28 Target Area Percents Target area percents are calculated by dividing the numerator count by the denominator count for each hospice for each time period, then multiplying by 100. Example: Live discharges; No Longer Terminally Ill: 28

29 Percentiles The target area percent lets the hospice know its billing patterns. More useful information comes from knowing how it compares to other hospices, which is why we calculate percentiles. Definition of a percentile: The percentage of hospices with a lower target area percent. 29

30 Percentiles, cont. To calculate percentiles for all hospices in a comparison group (nation, jurisdiction or state), the target area percents are sorted from largest to smallest for each time period. Example: If 40% of the hospices target area percents were lower than Hospice A, then Hospice A would be at the 40 th percentile. 30

31 Percentile Calculation Example 93% 85% 41% 20% 18% 7% 6% 5% 4% 2% 80 th percentile The top two hospices percents are at or above the 80 th percentile. 31

32 Comparisons in PEPPER PEPPER provides national, MAC jurisdiction and state comparisons. 32

33 About the MAC Jurisdiction The MAC jurisdictions in PEPPER correspond to current CMS Home Health/Hospice MAC jurisdictions: Jurisdiction K National Government Services Jurisdiction 15 CGS Jurisdiction M Palmetto Jurisdiction 6 National Government Services Map available: Contracting/Medicare-Administrative- Contractors/Downloads/HHH-Jurisdiction-Map-April pdf 33

34 Review: How Does PEPPER Identify Outliers? A hospice s target area percent is compared to other hospices percents in the nation, MAC jurisdiction and state. If the hospice s target area percent is at/above the national 80 th percentile, it is identified as at risk for improper Medicare payments. Compare and Target Area reports: Red bold print at or above the national 80 th percentile for the target area. 34

35 Hospice Top Terminal Conditions Lists the top terminal conditions for decedents for the most recent fiscal year. Utilize the terminal diagnosis conditions as defined by CMS (Medicare Hospice Data page on the CMS website). 35

36 Session 2: Hospice PEPPER Demonstration March, 2016 Kimberly Hrehor

37 Session 3: How to Use and Obtain Hospice PEPPER and Helpful Resources March, 2016 Kimberly Hrehor

38 Review: How Does PEPPER Identify Outliers? A hospice s target area percent is compared to other hospices percents in the nation, MAC jurisdiction and state. If the hospice s target area percent is at/above the national 80 th percentile, it is identified as at risk for improper Medicare payments. Compare and Target Area reports: Red bold print at or above the national 80 th percentile for the target area. 38

39 How to Prioritize PEPPER Findings Use the Compare Report. Consider risk status as compared to: 1. Nation 2. Jurisdiction 3. State Consider Target Count and Sum of Payments. Use Top Terminal Conditions reports to supplement analysis. 39

40 Sample Compare Targets Report These are the provider s exact percentiles they will not be the same as the 80 th percentiles on the target area reports. 40

41 Long LOS Target Area Report 41

42 Top Terminal Conditions Report 42

43 Hospice PEPPER User s Guide Documentation of episodes eligible for inclusion. Target area numerator and denominator definitions. Guidance on how to use PEPPER and how to interpret PEPPER findings. Available at PEPPERresources.org in the Hospice section 43

44 Using PEPPER Compliance can guide audits for areas at risk Audit results used to develop specific action plans for ensuring compliant documentation, providing education regarding admission necessity and improving system coding accuracy. Preparation for Recovery Auditors 44

45 National-level Data National-level data for all hospices in the nation for the target areas are available at PEPPERresources.org on the Data page; they are updated annually, following each release. 45

46 National-level Data Reports Program for Evaluating Payment

47 How to obtain your PEPPER PEPPER is distributed annually in electronic format. PEPPER Resources Portal Visit PEPPERresources.org Click on the PEPPER Distribution Get Your PEPPER link Review instructions and access portal Each release of PEPPER will be available for approximately two years from the original release date. PEPPER cannot be sent via . 47

48 Required Information to access PEPPER via the PEPPER Resources Portal 6-digit CMS Certification Number (also referred to as the provider number or PTAN). Not the same as the tax ID or NPI number Patient Control Number (form locator 03a) or Medical Record Number (form locator 03b) from claim of traditional fee-for-service Medicare beneficiary receiving services during the specified time period. 48

49 Required Information for Portal Access Patient Control Number (form locator 03a) or Medical Record Number (form locator 03b) from claim of traditional fee-for-service Medicare Part A beneficiary receiving services during specified period ( from or through date during that period). 49

50 Now what? Refer to the User s Guides. Share internally. Guide auditing and monitoring. Look for unusual increases/decreases. Identify root causes of concerning changes. Review medical records. Be proactive and preventive. 50

51 Strategies to Consider Do Not Panic! Indication of high outlier does not necessarily mean that compliance issues exist. But: Determine Why You are an Outlier Sample claims using same inclusion criteria. Review documentation in medical record. Review claim. Consider patient population, external factors. Ensure following best practices, even if not an outlier. 51

52 Who has Access to PEPPER? PEPPER is only available to the individual hospice. 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 hospices in their jurisdiction/region. 52

53 For assistance with PEPPER: View the PEPPER User s Guides at PEPPERresources.org. If you 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 QIO or any other organization for assistance with PEPPER. 53

54 Pepper Resources website Program for Evaluating Payment 54

55 Feedback on PEPPER We are interested in your comments and suggestions! 55

56 Together we can make a difference Program for Evaluating Payment Image of a faucet dripping money into a bucket Together, we can make a difference! 56