Your PEPPER report and QAPI

November 26, 2018

We covered the basics of the the PEPPER report in another article. As a reminder, it is a report based on claims data that you can access through the PEPPER Resources Portal. The PEPPER Resources websitehas more information including training documents and examples of how agencies have used the reports for improvement. Home Health PEPPER reports are updated around July 16th every year. This article will explore how your agency’s PEPPER report can contribute to your QAPI program.

How does it work?

The PEPPER report gives statistical data about your agency’s billing practices and then compares them to national, MAC jurisdiction and state numbers. It also trends three years of your agency’s data so you can monitor changes in your own agency’s billing trends and risk of improper Medicare payments. Any agency who performs at or above the 80th percentile in any of the risk criteria could face targeted medical reviews to determine if the billing is legitimate. Also keep in mind if the agency billing metrics significantly worsen from one year to the next, you may find yourself the focus of a targeted review. Start with the Compare tab of the report which gives a summary of your data with areas of concern printed in red.

Average Case Mix

Your Average Case Mix rate is calculated by adding the case mix values of episodes that are not LUPAs (Low Utilization Payment Adjustments) or PEPs (Partial Episode Payments) and dividing by the number of those episodes. If your rate is above the National 80th Percentile rate (1.16 for 2017) you may need to investigate how your OASIS clinical and functional questions are being answered and make sure that they are consistent with your patient’s documented condition.

Analyze your billing reports for claims with high case mix values to identify patient charts and personnel to focus on for your review. If errors are discovered, develop a plan to educate clinicians on the correct way to respond to OASIS items. Remember to re-assess by random chart audits after a short period of time to ensure that the staff member remains in compliance.

Average Number of Episodes

The total number of paid episodes divided by the number of unduplicated beneficiaries determines the Average Number of Episodes rate. For example, an agency who has been paid for 210 episodes provided to 100 unique patients would have a rate of 2.1 average number of episodes. This number can be helpful in determining whether your agency tends to recertify significantly more patients than other home health agencies. The National 80th Percentile rate for 2017 is 2.56 so if your agency has a rate that is higher, you could have an issue to investigate.

Review your agency’s number of episodes per patient and identify those beneficiaries who have a high number of recertifications. Audit documentation to ensure that continued home health services are skilled, reasonable and necessary. Review plans of care and any documented discharge plans to verify care and treatment are being provided in a thoughtful and efficient manner. Perform supervisory visits to assess the patient and the effectiveness of the care being provided by your clinician. Provide intervention and education for clinicians whose performance does not meet agency standards. Consider disciplinary actions for continuing non-compliance.

Episodes with 5 or 6 Visits

Episodes with 5 or 6 visits are calculated by counting the number of episodes with 5 or 6 visits and dividing that number by the total number of episodes during that same period. For 2017, the National 80th Percentile limit was 9.8%. CMS assumes that agencies may try to “game the system” by squeezing in an extra visit or two to avoid a LUPA adjustment and receive the full payment.

If your agency rate of Episodes with 5 or 6 visits is over 9.8% in 2017, you should identify the episodes where 5 or 6 visits were performed. Exclude episodes where the reason for the limited number of visits was admission to an inpatient facility. Determine whether the care plans were clinically appropriate and if interventions and goals could have been achieved with fewer visits. If patient refusal of services was a problem, identify clinicians who had high rates of refusal and re-educate them in provision of home health care services and appropriate responses to client refusals. Offer assistance through your clinical management for intervention and support or re-staffing for difficult patients or family members.

Non-LUPA Payments

Your agency Non-LUPA Payments rate is calculated by dividing the number of episodes that did not have a LUPA adjustment by the total number of episodes billed in the reporting period. The National 80th Percentile for 2017 was 97.4%. If your agency rate was above 97.4% in 2017, you should perform the reviews discussed above for Episodes with 5 or 6 Visits. This metric is also used by CMS to attempt to identify agencies gaming the system by creating non-LUPA episodes where a 4 visit or less approach may have been more clinically appropriate.

High Therapy Utilization Episodes

The number of episodes billed with 20 or more therapy visits divided by the total number of episodes during the reporting period gives you the High Therapy Utilization Episodes rate. For 2017, the National 80th Percentile rate was 14.9% so any agency whose rate was above 14.9% could be at risk for improper billing practices.

If your agency performed above this metric, identify patients who were provided 20 or more therapy visits in the episode. You can start with episodes whose first digit of the HHRG was “5”. However, you may need to review claims data to ensure that therapists did not order additional visits after the initial plan of care was established. Audit the documentation of the therapists to ensure that services were skilled, reasonable and necessary. Identify therapy staff whose documentation may not support higher therapy utilization and provide appropriate educational and disciplinary interventions. If the therapist is a contract employee, involve the therapy company management. For continued non-compliance, request alternative staffing or consider using a different therapy company.

Outlier Payments

Your agency Outlier Payments percentage is calculated by dividing the sum of the outlier payment amounts by the total sum of all payments for episodes in the reporting period. For 2017, the National 80th Percentile rate was 7.3% so any agency whose outlier rate was above 7.3% could be at risk.

If your agency rate was above 7.3%, identify claims with outlier payments. Review documentation for the big three: skilled, reasonable and necessary. See if you can tie increased utilization to certain clinicians. Consider a review program where frequencies are discussed at plan of care and any time new orders are written to increase the number of visits in the episode to ensure over-utilization is identified early.

After Identification

Remember, these numbers reflect trends in home health. Don’t panic if you have a number that is over the 80th percentile. If your patient population requires the level of care you are providing and your documentation supports your plan and follow-through then you will be ok. You may be exposed to a higher number of clinical record review requests but if your clinical notes show a consistent picture of skilled, reasonable and necessary services you should not be denied.

Make sure that you keep records of your QAPI program to provide evidence to surveyors who may ask about problem areas. Chart audits, supervisory visits and other actions must be documented as well as performed to demonstrate a paper trail of the work you have done. Like we tell clinicians: “if you didn’t document it, you didn’t do it.”

More Information

If you would like more information about PEPPER reports, check out the official website. To submit questions about this article, connect with uson Facebook.