Healthcare Provider Solutions
*UPDATED – 05/26/17 – 4:07PM CST

One of the Hot Topics surrounding the medical review contractors and Medicare MACs is Home Health PEPPER (Program for Evaluating Payment Patterns Electronic Report)!

Pepper is an accumulation and calculation of certain statistics that result from claims data. These Medicare claims data statistics are calculated for areas that may be at risk for improper Medicare payments such as coding, billing errors, long lengths of stay, etc.  It compares your agency’s claims data statistics with aggregate Medicare data for the nation, the state and MAC Jurisdiction.

The most recent update to these reports will be issued July 2017.  Hopefully, someone in each agency has already begun a thorough review of these reports to determine if there is a possibility of issues/flags that the agency needs to focus on correcting or improving.

  • One of the Target Areas is Average Case Mix – This calculation looks at the agency’s case mix compared to the 80th percentile of the Nation, State and Medicare MAC Jurisdiction. If the agency has a higher Average Case Mix than these the agency will be flagged as an outlier.  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.

There are multiple other Target Areas and other reports of statistical data within the PEPPER files.  Someone from your agency should specifically be assigned the task of analysis and establishing a corrective action plan if necessary.  HPS Alliance Members are being offered a webinar, specific to Home Health PEPPER reports, as part of their membership.  This session will be June 8, 2017.  Please register today!

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.

June 8th, 2017 we will be providing our HPS Alliance members with a review of the Home Health PEPPER Reports. We will discuss the gathering of data as well as reading and understanding the PEPPER reports. Agencies are being scrutinized by medical review contractors as a result of the data on these reports, so agencies need to fully understand them and understand what the agency can do to improve their data. Join us on June 8 for a HOT webinar on Understanding the HOME HEALTH PEPPER!