Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report Inpatient Psychiatric Facility (IPF) and Partial Hospitalization Program (PHP) PEPPER Update April 11, 2016 Kimberly Hrehor and Dan McCullough

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report Agenda  What is PEPPER?  What’s new in the IPF PEPPER? – Three new target areas – Revised target area  What’s new in the PHP PEPPER? – One new target area, one discontinued target area – Production schedule change to calendar year  How to obtain PEPPER  Questions and Answers 2

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report What is PEPPER?  Program for Evaluating Payment Patterns Electronic Report (PEPPER) summarizes Medicare claims data statistics for one provider in areas (“target areas”) that may be at risk for improper Medicare payments.  PEPPER compares the provider’s Medicare claims data statistics with aggregate Medicare data for the nation, MAC jurisdiction and state.  PEPPER cannot identify improper Medicare payments! 3

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report History of PEPPER  PEPPER was originally developed in 2003 for short-term acute care PPS hospitals.  Was later developed for: – Long-term acute care PPS hospitals (2005) – Critical access hospitals (2011) – Inpatient psychiatric facilities (2011) – Inpatient rehabilitation facilities (2011) – Partial hospitalization programs (2012) – Hospices (2012) – Skilled nursing facilities (2013) – Home health agencies (2015) 4

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report Why is CMS Providing 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

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report How Can Providers Use PEPPER?  PEPPER is a roadmap to help you identify potentially vulnerable or improper payments.  Providers are not required to use PEPPER or to take any action in response to their PEPPER statistics.  But: Why not take advantage of this free comparative report provided by CMS? 6

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report PEPPER Data  Organized in three 12-month time periods based on federal fiscal year (FY).  Q4FY15 release contains statistics for IPF discharges that end between Oct. 1, 2012 through Sept. 30, 2015 (fiscal years 2013, 2014 and 2015). 7 FY 2013FY 2014FY 2015

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report Target Area  Area identified as potentially at risk for improper payments (coding or billing errors, unnecessary admissions)  Constructed as a ratio: – Numerator = discharges identified as potentially problematic – Denominator = larger reference group 8

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report IPF PEPPER Target Areas Target AreaTarget Area Definition Comorbidities *revised in Q4FY15 release N: count of discharges with at least one comorbidity on the claim D: count of all discharges No Secondary Diagnoses *new in Q4FY15 release N: count of discharges with no secondary diagnosis codes D: count of all discharges Outlier Payments N: count of discharges with an outlier approved amount greater than $0 D: count of all discharges 9

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report IPF PEPPER Target Areas, 2 Target AreaTarget Area Definition 3- to 5-day Readmissions N: count of index (first) admissions for which a readmission occurred within 3 to 5 calendar days (4 to 6 consecutive days) to the same IPF or to another IPF for the same beneficiary D: count of all discharges excluding patient discharge status code 20 (expired) 30-day Readmissions *revised in Q4FY15 release N: count of index (first) admissions for which a readmission occurred within 30 days to the same IPF or to another IPF for the same beneficiary (identified using the Health Insurance Claim number), excluding patient discharge status codes 65 (discharged/transferred to an IPF), 93 (discharged/transferred to an IPF with planned acute care hospital readmission), 07 (left against medical advice) D: count of all discharges excluding patient discharge status codes 65, 20, 93, 07 10

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report IPF PEPPER Target Areas, 3 Target AreaTarget Area Definition One-day Stays *new in Q4FY15 release N: count of discharges where the beneficiary was admitted and discharged on the same day or was discharged on the day after admission D: count of all discharges No Ancillary Charges *new in Q4FY15 release N: count of discharges with no ancillary charges on the claim D: count of all discharges 11

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report PHP PEPPER Target Areas Target AreaTarget Area Definition Days of Service with 4 Units Billed N: count of episodes of care (EOC) ending in the report period with only days of service with exactly 4 units billed D: count of all EOC ending in the report period Group TherapyN: count of EOC ending in the report period with only group therapy (revenue code 0915) billed D: count of all EOC ending in the report period No Individual Psychotherapy N: count of EOC ending in the report period with no units of individual psychotherapy (revenue code 0914) or psychiatric testing (revenue codes 0900 or 0918) D: count of all EOC ending in the report period 12

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report PHP PEPPER Target Areas, 2 Target AreaTarget Area Definition 60+ Days of Service N: count of EOC ending in the report period with greater than or equal to 60 days of service provided by the PHP D: count of all EOC ending in the report period 30-Day Readmissions N: count of all index (first) EOC ending in the report period for which a resumption of care occurred within 30 days to the same or to another PHP D: count of all EOC ending in the report period Outlier Payments *new in Q4FY15 release N: count of episodes of care ending in the report period with at least one claim with an outlier payment (value code = 17) D: count of episodes of care ending in the report period 13

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report 14 Percentile Calculation Example  The top two IPFs’ percents are at or above the 80 th percentile.  The bottom two IPFs’ percents are at or below the 20 th percentile. 13% 12% 8% 44% 21% 20% 18% 15% 14% 80 th percentile 20 th percentile 23% 13% 12% 8%

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report National-level Data  National-level and state-level data for the target areas (number of discharges for the numerator/denominator, average length of stay, total payments) is available at PEPPERresources.org on the “Data” page  Available for all IPFs, free-standing IPFs and IPF distinct part units.  Updated annually following each report release. 15

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report How is IPF PEPPER distributed?  Electronically via QualityNet (QN) to QN administrators and those with basic QN accounts and the PEPPER recipient role. – If there is no QualityNet administrator at your IPF, or if your IPF’s QualityNet administrator needs assistance, contact the QualityNet Help Desk at  PEPPER cannot be sent via .  IPF PEPPER will be distributed annually. 16

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report How Can I Receive PEPPER?  Work with your hospital’s QualityNet administrator to obtain a basic user account.  Ask for “PEPPER recipient” and “File Exchange and Search” roles.  Next IPF PEPPER will be distributed the week of April 11-15,  Next PHP PEPPER will be distributed July 18, – Hospital- and IPF-based PHPs will receive via QualityNet – Other PHPs will receive via PEPPER Resources Portal 21

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report Helpful Suggestions:  AutoRoute_inbox  May receive twice if have both roles (QualityNet Administrator and PEPPER Recipient)  Download within 60 days of when file uploaded  Trouble downloading or opening? – Try Google Chrome as browser

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report 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; was it coded and billed appropriately based upon documentation in medical record?  Ensure following best practices, even if not an outlier. 23

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report For assistance with PEPPER:  Visit PEPPERresources.org for the PEPPER User’s Guide and training materials.  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/association for assistance with PEPPER. 24

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report 25 Pepper Resources website

Program for Evaluating Payment Patterns Electronic Report Program for Evaluating Payment Patterns Electronic Report Questions?  “Help Desk” at PEPPERresources.org