PEPPER - Program for Evaluating Payment Pattern Electronic Report

Contains the Skilled Nursing Facility’s claims data statistics for areas that may be at risk for improper Medicare payment

Compares SNF’s Medicare data with aggregate Medicare data for state, MAC jurisdiction and nation

View of where billing patterns differ from other facilities so the facility can “proactively monitor and take preventative measures”

Office of Inspector General (OIG) requires that Medicare providers have a compliance program in place to be sure services provided are reasonable and necessary prevent fraud and abuse. Review of this material should be part of that program.

Q4FY2012 runs Oct 1, 2009 thru Sept 30, 2012 Beneficiary Episode of Care (EOC)ends during the time period it will be included in the PEPPER

Risk areas are “target areas” = an area that is prone to improper billing 6 target areas area looked at:  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 (Persistent High levels of ADLs are reimbursed at higher rates and subject to improper coding.)  Non-Therapy RUGs with high ADLs- N: Count of days billed with RUG equal to SSC, CC2, CC1, BB2, BB1, PE2, PE1, IB2, IB1, in RUGIII; HE2, HE1, LE2, LE1, CE2, CE1, BB2, BB1, PE2, PE1 in RUSIV; D: Count of days billed for all non-therapy RUGs (Persistent High levels of ADLs are reimbursed at higher rates and subject to improper coding.)  Change of Therapy Assessments- N: Count of assessments with second digits “D” D: Count of all Assessments (high proportion = problem with provision of services; OIG is watching for very few COT or none at all = may not be compliant with scheduling and may be targeted by MAC for review)  Ultra High 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 (not all beneficiaries are appropriate for Ultra High levels, % should reflect appropriate/necessary levels)  Therapy RUGs- N: Count of days billed for all therapy RUGs: D: Count of all therapy and non-therapy RUGs (SNF should provide appropriate and necessary services both nursing and therapy levels)  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 (SNF should ensure beneficiary received skilled care that is necessary and that is skilled during the entire duration of the stay)

To find a PERCENT: Divide the numerator by the Denominator then multiply by 100 Numerator = count of RUG Days/episodes of care meeting the definition Denominator = count of RUG Days/episodes of care meeting the definition PEPPER - Program for Evaluating Payment Pattern Electronic Report

The PERCENT is the facility’s number/value for the Target Area. The PERCENT is different than the PERCENTILE.

PERCENTILE is the gauge to compare that percent to all other SNFs. Once all the SNFs’ percents are listed high to low we can determine who is at the high end and who is at the low end and where the middle 60% lies. The SNF’s in the top and bottom 20% are called “Outliers”.

If the facility is in identifiable print (for National Comparison Group) it is considered an outlier and “at risk” for improper payments: RED BOLD print- at or above the national 80th percentile for the target area or GREEN ITALIC print- at or below the national 20th percentiles for the target area (First two ADL areas at risk for undercoding only)

Compare Targets Report can be very helpful and a quick summary- All 6 target areas area listed for the most recent time frame The first column lists the Target area Second column tells what is being measured Third column tells you how many is in your numerator Forth column tells you your facility percent- this doesn’t give you much information until that percent is compared with all the other facilities. If the number is in RED it means you are in the 80th percentile nationally-look to the next column to see >80%. If it is GREEN, you are in the lower 20% percentile nationally (will only be in the first two Targets). Fifth column tells you where your facility ranks among other SNFs in the nation- This percent of the SNFs in the nation rank below you in the standings. Sixth column tells you where your facility ranks among other SNFs in the state- This percent of the SNFs in the state rank below you in the standings. Seventh column tells you where your facility ranks among other SNFs in the MAC jurisdiction- This percent of the SNFs in the jurisdiction rank below you in the standings.

Individual Report Pages have more detailed data The Graph- The Blue Bar is your facility the Red line is the 80th percentile “trend line”, the green “trend line” is the 20th percentile line. If your blue bar extends above the red or is below the green for any time period, your facility is considered at risk for overpayment. The Table- Contains detailed information for each time frame for your facility and for the 80th percentile and 20th percentile group for comparison. Suggestion Interventions for Outliers- This area is included to help determine if you should audit a sample of records. There may also be suggestions for interventions for improvements for this target area.

** If your facility has a Numerator count of 11 or less or if the state or MAC/FI count is 11 or less, the data will be blank in your tables and graph- or you may not even get a PEPPER.

The included RUGs Reports are informational only: Top 20 RUGs Top 20 RUGs for Episodes of Care >90 days Top RUGs for all EOC- For the Jurisdiction for Comparison Top RUGs for EOC >90 days for the Jurisdiction for comparison