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PEPPER Reports: Analyze Your Risk for Improper Payments

September 20, 2019
Compliance By Patty Klinefelter, Director

The Q4 CY18 release of the Home Health Agency (HHA) Program for Evaluating Payment Patterns Electronic Report (PEPPER), with statistics through December 2018, is now available for download through the PEPPER Resources Portal. The report is available without cost to CEOs, presidents, administrators or compliance officers. A six-digit CMS Certification Number is needed as a measure to preserve confidentiality. This is a valuable resource that is sometimes overlooked by compliance leadership.

The Centers for Medicare & Medicaid Services (CMS) is mandated to protect the Medicare Trust fund from fraud, abuse and waste. One of several strategies used is the PEPPER report.

CMS contracts with TMF Quality Institute to develop, produce and disseminate PEPPER reports. The reports use comparative data to find services that are possibly at a high risk for improper payments and are used as an educational tool to help providers assess these risks for improper payments.  The report summarizes a provider’s claims data statistics and compares the data with aggregate Medicare data from other providers.

Home health reports are distributed annually, at no cost, to registered users and are confidential. The reports identify outliers for targeted areas and cannot identify "individual, patient-specific" improper Medicare payments. The report summarizes statistics for three federal fiscal years and is refreshed with each release with the oldest fiscal year rolling off with the new year added.

Home Health targeted areas are case mix, average number of episodes, episodes with 5 or 6 visits, non-LUPA payments, high therapy utilization and outlier payments.. The most important part of the PEPPER Report shows the agency’s statistics for all targeted areas for the most current calendar year. Outlier data is color coded with high outliers shown in red and low outliers shown in green. The agency’s data is compared to the national, jurisdiction and state data.

Other areas of the PEPPER Report provide individual tabs for each targeted area and include suggested interventions which are noted when the targeted area is above the 80th percentile.

In addition, the report provides data of the top home health diagnosis and top home health therapy episodes comparing individual agencies with national, state and jurisdiction data.

 

Some key points from the recently released "Target Area Summary" are shown below:

 

PEPPER Target Area graph

 

The chart below shows the "Top Diagnosis for Q4 CY 18" with the average number of visits:

 

PEPPER blog diagnosis graph

 

After retrieving your report, LW Consulting, Inc. suggests you analyze the report, identify outliers which are the 80 or 20 percentile, incorporate the new information into the agency’s QAPI/Compliance program, use as a guide for auditing and monitoring efforts to help identify and prevent payment errors and audit medical records to determine if documentation supports the claim.

 

 For more information on how we can assist your agency in interpreting your report and determining your next steps, contact Patty Klinefelter at 540-686-1311 or email PKlinefelter@LW-Consult.com.

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