Healthcare Provider Solutions

Over the past couple of years, HPS has reported and discussed that Home Health and Hospice PEPPER Reports are very important and should be reviewed by all agencies. We have also been open about the number of agencies in the country that have never opened the reports. HPS is happy to report that, for the 8 months ending December 20, 2017, 58.5% of all hospices have opened their reports. Only 5 states and 1 territory are below 50%. The sad news is that home care is still below 29% overall and 35 states and 2 territories are below 50% with 4 states being below 20%.

Why so much emphasis on these reports? How can it be that important if that many agencies have not even opened their first one?

These reports are a representation of the agency’s claims data. When the Medicare MACs are working toward who should be targeted under the current Targeted Probe & Educate program, they are likely using the PEPPER as one of the determining factors. In the aforementioned HPS blog regarding Hospice Targeted Probe & Educate there were some details regarding the targets that are a part of these reports.

From a home care perspective, most of the targets are items that have caused the Medicare MACs to question the practices of the agency for years.

  • One of the Target Areas is Average Case Mix – This calculation looks at the agency’s case mix compared to the 80thpercentile of the Nation, State, and Medicare MAC Jurisdiction. If the agency has a higher Average Case Mix than the National 80th percentile the agency’s number will be in red. This would lead medical reviewers to be suspicious of upcoding, etc. on the OASIS to cause the higher case mix weight and thus higher reimbursement.
  • Another Target Area is High Therapy Utilization – This calculation is comparing the agency’s number of therapy episodes with 20+ therapy visits to the 80th percentile of the Nation, State, and Medicare MAC Jurisdiction. Agencies having a higher percentage of these high therapy episodes would lead medical reviewers to be suspicious of therapy services being provided that may not be medically necessary.
  • Two of the targets are associated with each other. The agency’s number of episodes with exactly 5 or 6 visits and the percentage of episodes that do NOT result in a LUPA (Low Utilization Payment Adjustment). The medical reviewer that sees an agency with episodes having exactly 5 or 6 visits that are in excess of the National 80th percentile is going to leave the reviewer assuming that the agency may have been simply trying to avoid the LUPA adjustment. If the agency is in excess of the National 80th percentile for episodes NOT resulting in a LUPA, in addition, to be in excess of episodes having exactly 5 or 6 visits, there will definitely be questions about the agencies policies and practices of trying to avoid the LUPA adjustment.

Home care agencies should not believe that they will be completely free from scrutiny just because their numbers are not RED, but should be very cautious of any of their numbers that are close to the National 80th percentile and be prepared for possible additional reviews. Agencies should also take a hard look at any of the numbers that are really close and review current processes etc. to ensure that the numbers will not be red in subsequent years. The reports are only released once per year. Hospice in April and Home Care in July. Once the next reports are released it will be too late to work on that data.

Please do not be an agency that is part of the negative statistics! Get your PEPPER today and let the data help prepare the agency for any future audits. For more information on how to access your data and use it visit https://www.pepperresources.org/ Where you can sign up to join the email list and receive updates on training and distribution.

If the agency becomes subject to Targeted Probe & Educate and you need assistance in compiling the charts and reviewing prior to submission or in appeals, HPS will be glad to help.

Lastly, HPS Alliance members have access to our recorded webinars the following is a link to that page. HPS Alliance Recorded Webinars