The fourth quarter fiscal year 2020 Program for Evaluating Payment Patterns Electronic Reports (PEPPER) can now be accessed. The PEPPER reports summarize provider-specific data for Medicare services that may be at risk for improper payments.
In 2012, the Office of Inspector General (OIG) found that approximately 25% of skilled nursing facilities (SNFs) were billing in error. As part of its compliance program, a SNF should conduct regular audits to ensure services provided are necessary, and that charges for Medicare services are correctly documented and billed. The PEPPER report can help SNFs with auditing and monitoring activities.
PEPPER data was analyzed to identify areas within the SNF prospective payment system (PPS) that could be at risk for improper Medicare payment. These areas are referred to as “target areas.” The PEPPER data report addresses a SNF’s Medicare statistics for target areas. Data is obtained from the UB-04 claims submitted to the Medicare Administrative Contractor (MAC) by the SNF.
The PEPPER target areas have been identified by the Centers for Medicare & Medicaid Services (CMS) as being potentially at risk for improper Medicare payments. A high target area percent does not necessarily indicate the presence of improper payment or that the provider is doing anything wrong; however, providers should review their medical record documentation to ensure that the services their beneficiaries receive are appropriate and necessary, as well as to ensure that the documentation in the medical record supports the level of care and services for which they have received Medicare reimbursement.
SNF target areas include:
- Patient Driven Payment Model (PDPM) High Utilization Codes
- New as of the Q4FY20 release
- 20 Day Episodes of Care
- 90+ Day Episodes of Care
- 3-5 Day Readmission
- New as of the Q4FY19 release
SNFs should use PEPPER as a guide for auditing and monitoring their Medicare claims. A SNF can use PEPPER to compare its claims data over time to identify areas of potential concern and to identify changes in billing practices. Areas that most often flag for OIG review in PEPPER Reports are at or below the 20th percentile of benchmarked data or at or above the 80th percentile for the target areas in a SNF’s report. It is recommended that prior to submitting claims for reimbursement, a facility schedule regular meetings that are attended by the director of nursing, MDS coordinator, therapy director, business office manager, and other appropriate team members to verify that all aspects of care, documentation, and/or billing meet all Medicare regulations prior to claim submission.
The report displays how a SNF’s data compares to aggregate jurisdiction, state, and national statistics. The statistics in PEPPER are presented in tabular form and in graphs that depict the SNF’s target area percentages over time. The data tables, graphs, and reports in PEPPER are designed to assist SNFs with the identification of potentially improper payment.
A PEPPER distribution webpage for guidance to accessing your report can be accessed at: Distribution Schedule – Get Your PEPPER (cbrpepper.org).
A PEPPER Resources website that includes a user’s guide, recorded training sessions, and FAQ’s can be accessed at PEPPER Resources (cbrpepper.org).
Issue:
Reviewing and analyzing your facility’s PEPPER information can reduce the possibility of inadvertently submitting false claims to Medicare. Ensure that all staff are aware that these violations can occur, whether they are intentional or not intentional. In addition to a multidisciplinary meeting reviewing Medicare claims prior to submission, the compliance and ethics committee should be reviewing and discussing the facility’s PEPPER as part of their monthly auditing and monitoring tasks. Failure to promptly report a false claim can result in fines and other sanctions. Additional information is available in the Med-Net Corporate Compliance and Ethics Manual, Chapter 2 Financial Integrity, CP 2.3 General Legal Duties and Antitrust Laws.
Discussion Points:
- Review policies and procedures for preventing and reporting a false claim. Update your policies and procedures as needed.
- Train all staff on the False Claims Act and what can be considered a false claim. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Document that the trainings occurred and place in each employee’s education file.
- Periodically audit staff to ensure that they are aware of what should be done if they suspect a false claim has occurred, whether intentionally or unintentionally. Conduct audits of documentation and billing practices routinely to prevent and detect errors before they progress to a false claim.
