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Program for Evaluating Payment Patterns Electronic Report
Using the Inpatient Psychiatric Facility (IPF) PEPPER to Support Auditing and Monitoring Efforts:
Session 1
March, 2016 Kimberly Hrehor
Program for Evaluating Payment Patterns Electronic Report
Agenda Session 1:
– History and basics of PEPPER – IPF PEPPER target areas – Percents and percentiles – Comparison groups
Session 2: PEPPER Demonstration Session 3:
– How to use and obtain PEPPER – Helpful resources
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Program for Evaluating Payment Patterns Electronic Report
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.
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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 IPF in areas (“target areas”) that may be at risk for improper Medicare payments. PEPPER compares an IPF’s Medicare claims data
statistics with aggregate Medicare data for the nation, MAC jurisdiction and state. PEPPER cannot identify improper Medicare payments!
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Program for Evaluating Payment Patterns Electronic Report
History of PEPPER PEPPER was originally developed in 2003 for
short-term acute care PPS hospitals. PEPPER is also available 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
Program for Evaluating Payment Patterns Electronic Report
Why are IPFs 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.
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Program for Evaluating Payment Patterns Electronic Report
PEPPER Summarizes Medicare Data Paid inpatient Medicare claims
– Inpatient psychiatric facility or distinct part unit – Claim facility type = hospital – Inpatient part A claim – Claim has a valid medical record number – Medicare claim payment amount > $0 (Medicare
Secondary Payer claims are included) – Final action claim – Exclude HMO claims – Exclude canceled claims
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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 discharges at the IPF that end between Oct. 1, 2012 through Sept. 30, 2015 (fiscal years 2013, 2014 and 2015). 8
FY 2013 FY 2014 FY 2015
Program for Evaluating Payment Patterns Electronic Report
PEPPER Data Restriction
Due to CMS data restrictions, the PEPPER will not display statistics when the numerator or denominator count is less than 11 for a target area in any time period. – Some providers may not see any
data for some target areas or time periods.
– Some providers will not have a PEPPER available.
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Program for Evaluating Payment Patterns Electronic Report
IPF Improper Payment Risks PEPPER does not identify improper payments. IPFs are reimbursed through the IPF prospective payment
system (PPS). IPFs can be at risk for improper Medicare payments due to
coding errors or unnecessary admissions. IPF PEPPER target areas were identified based on a review
of the IPF PPS, coordination with CMS IPF subject matter experts and analysis of national claims data.
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Program for Evaluating Payment Patterns Electronic Report
Target Area Area identified as potentially at risk for improper
payments Focused on admission necessity or coding issues Constructed as a ratio:
– Numerator = discharges identified as potentially problematic (likely to be miscoded or admitted unnecessarily)
– Denominator = larger reference group that contains the numerator
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Program for Evaluating Payment Patterns Electronic Report
IPF PEPPER Target Areas Target Area Target 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
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Program for Evaluating Payment Patterns Electronic Report
IPF PEPPER Target Areas, 2 Target Area Target 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
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Program for Evaluating Payment Patterns Electronic Report
IPF PEPPER Target Areas, 3 Target Area Target 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
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Program for Evaluating Payment Patterns Electronic Report
Three Basic Statistics Count of discharges (numerator and
denominator) Payments (sum and average) Average length of stay
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Program for Evaluating Payment Patterns Electronic Report
Percents and Percentiles Percents and percentiles are at the heart of
PEPPER. It is easy to confuse these terms. The following slides clarify the definitions
and how they relate to each other in PEPPER. 16
Program for Evaluating Payment Patterns Electronic Report
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Target Area Statistics Numerator – number of target area
discharges; will not display if <11 Denominator – number of all denominator
discharges; will not display if <11
Program for Evaluating Payment Patterns Electronic Report
Target Area Percents Target area percents are calculated by dividing
the number of target discharges by the number of denominator discharges for each provider for each time period, then multiplying by 100. Example: Comorbidities
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Program for Evaluating Payment Patterns Electronic Report
Percentiles The target area percent lets the IPF know its
billing patterns. More useful information comes from knowing
how it compares to other IPFs, which is why we calculate percentiles. Definition of a percentile:
– The percentage of IPFs with a lower target area percent.
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Program for Evaluating Payment Patterns Electronic Report
Percentiles, cont. To calculate percentiles for all IPFs 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 IPFs’ target area percents were lower than IPF A, then IPF A would be at the 40th percentile.
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Program for Evaluating Payment Patterns Electronic Report
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Percentile Calculation Example
The top two IPFs’ percents are at or above the 80th percentile. The bottom two IPFs’
percents are at or below the 20th percentile.
13%
12%
8%
44%
21%
20%
18%
15%
14%
80th
percentile
20th
percentile
23%
13%
12%
8%
Program for Evaluating Payment Patterns Electronic Report
Comparisons in PEPPER PEPPER provides
state, MAC jurisdiction and national comparisons.
State Comparison
MAC Jurisdiction Comparison
National Comparison
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Program for Evaluating Payment Patterns Electronic Report
Review: How does PEPPER identify Providers at Risk? A provider’s target area percent is compared to other providers’
percents in the nation, MAC jurisdiction and state. If the provider’s target area percent is at/above the national 80th
percentile or at/below the national 20th percentile, it 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).
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Program for Evaluating Payment Patterns Electronic Report
Top DRG Report Lists the top DRGs for the IPF by number of
discharges that end in the most recent fiscal year. Includes number of discharges for the DRG,
the proportion of discharges for the DRG to total discharges, and the ALOS for the DRG. Supplemental report; has no impact on
outlier status or risk for improper payments. 25
Program for Evaluating Payment Patterns Electronic Report
Jurisdiction Top DRG Report Lists the top DRGs by number of discharges in
the most recent fiscal year for all IPFs in the MAC jurisdiction. Include same data elements as the IPF-
specific report, as well as the jurisdiction and national ALOS for the top DRGs.
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Program for Evaluating Payment Patterns Electronic Report
Session 2: IPF PEPPER Demonstration
March, 2016 Kimberly Hrehor
Program for Evaluating Payment Patterns Electronic Report
Session 3: How to Use and Obtain IPF
PEPPER and Helpful Resources
March, 2016 Kimberly Hrehor
Program for Evaluating Payment Patterns Electronic Report
Review – How does PEPPER identify Potential Risk? A provider’s target area percent is compared to other IPFs’
percents in the nation, MAC jurisdiction and state. If the IPF’s target area percent is at/above the national 80th
percentile or at/below the national 20th percentile, it 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).
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Program for Evaluating Payment Patterns Electronic Report
How to Prioritize PEPPER Findings Use the Compare Targets Report. Consider outlier status compared to:
1. Nation 2. Jurisdiction 3. State
Consider “Number of Target Discharges” and “Sum of Payments.” Refer to the target area reports for specifics,
changes over time. Use “Top DRGs” report to supplement analysis.
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Program for Evaluating Payment Patterns Electronic Report
IPF PEPPER User’s Guide Documentation of claims 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
“Inpatient Psychiatric Facilities” section
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Program for Evaluating Payment Patterns Electronic Report
Using PEPPER Coding – data source for DRG validation audits
– Consider selecting cases to review from the numerator for high outliers.
– You may wish to further target records for review (e.g., by length of stay).
– Share findings internally with coders; use as springboard for discussion and education.
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Program for Evaluating Payment Patterns Electronic Report
Using PEPPER , 2 Compliance – can guide audits for outlier areas
– Audit results used to develop specific action plans for ensuring compliant documentation, providing education regarding admission necessity and improving coding accuracy.
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Program for Evaluating Payment Patterns Electronic Report
Using PEPPER Utilization review/quality
– Consider selecting cases for review from the numerator.
– You may wish to further target records for review (e.g., readmissions).
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Program for Evaluating Payment Patterns Electronic Report
Using PEPPER, 3 Preparation for Recovery Auditors Support of auditing, monitoring and
benchmarking activities
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Program for Evaluating Payment Patterns Electronic Report
National-level Data National-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 and updated following each release. Available for all IPFs, free-standing IPFs and
IPF distinct part units. 36
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 www.qualitynet.org
PEPPER cannot be sent via e-mail. IPF PEPPER will be distributed annually.
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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.
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Program for Evaluating Payment Patterns Electronic Report
Now what? Refer to the user’s guides. Share internally. Guide auditing and monitoring. Look for increases or decreases, identify root
causes. Review medical records. Be proactive and preventive.
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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. 44
Program for Evaluating Payment Patterns Electronic Report
Who has Access to PEPPER? PEPPER is only available to the individual
provider. 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 providers in their jurisdiction/region.
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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.
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Program for Evaluating Payment Patterns Electronic Report
Feedback on PEPPER We are interested in your comments and
suggestions!
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