interpreting your 2014 snf pepper

Program for Evaluating Payment Patterns Electronic Report:

Interpreting Your 2014 SNF PEPPER

Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 1

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)Presented by:

Kris Mastrangelo, OTR/L, MBA, LNHA President and CEO

Keri A. Hart, MS-CCC/SLP, RAC-CT, CHHRP-QTVice President of Clinical Operations/Education and Training

Harmony Healthcare International, Inc. 2

About Kris

Kris Mastrangelo, OTR/L, MBA, LNHA

Kris Mastrangelo, President and CEO, owns and

operates Harmony Healthcare International, (HHI)

an industry leader in Long Term Care consulting.

14,000 Medical records reviewed per year

Core Business Patient Centered

Follow Me! @KrisMastrangeloCopyright © 2014 All Rights Reserved

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About Keri

Keri Hart, MS-CCC, SLP, RAC-CT, CHHRP-QT

Keri Hart is the Vice President Clinical Operations/Education and Training at Harmony Healthcare International, (HHI) an industry leader in Long Term Care consulting.

Over 25 Years Experience in Long-term

Care

Rehabilitation Management

MDS

Follow Me! @CHHRPHart

Copyright © 2014 All Rights Reserved



Program for Evaluating Payment Patterns Electronic Report: Interpreting Your 2014 SNF PEPPER

Disclosure: The planners and presenters of this education activity have no relationship with commercial entities or conflicts of interest to disclosePlanners:

Kris Mastrangelo, OTR/L, MBA, LNHAElisa Bovee, MS, OTR/LDiane Buckley, BSN, RN, RAC-CTKeri Hart, MS-CCC/SLP, RAC-CT, CHHRP-QT

Presenters: Kris Mastrangelo, OTR/L, MBA, LNHA Keri Hart, MS-CCC/SLP, RAC-CT,

CHHRP-QTCopyright © 2014 All Rights Reserved

Objectives

Learner will be able to:

State three variables contributing to initiation of the PEPPER in the long-term care setting

Discuss the relevance of PEPPER percentile ranking

Define the calculations leading to Pepper Target Areas

Communicate a summary of their PEPPER data to key staff

Identify their facility specific risk factors for Medicare reviews

Develop a facility specific action plan in response to PEPPER Data


PEPPER

This report will contain the SNFs detailed facility specific Medicare claims data in certain targeted areas and compare the SNF to other SNFs nationally

Skilled Nursing Facilities (SNFs) should sign up to receive email notification that your PEPPER is available

PEPPERResources.org from the PEPPER HELP Desk(http://pepperresources.org/HelpContactUs.aspx)


http://pepperresources.org/HelpContactUs.aspx

Where is My Pepper?

Updated Release Schedule: On or about May 6 through May 12, 2014

Staged Release

Freestanding SNFs will receive via a secure portal on the PEPPERresources.org website

SNFs/Swing beds that are part of a short-term acute care hospital (3rd digit in the PTAN/CMS certification number/provider number = “U”) will receive electronically via QualityNet secure file exchange


Accessing Your SNF PEPPER

Access to the PEPPER will be restricted to the provider’s Chief Executive Officer, President or Administrator

Corporate offices and/or facility management companies will need to obtain PEPPERs from each individual provider in their organization



What you will need:

Facility specific 6-digit CMS Certification Number

The 3rd digit of this number will be a 5 or a 6

This is not the same number as the tax identification number or national provider identification number



For verification purposes, requestors will be required to enter either one of the following from the UB-04 for a fee-for-service Medicare patient who received services at the provider between September 1-30, 2013:

A Patient Control Number (found at form locator 03a on the UB04 claim form)

or

A Medical Record Number (found at form locator 03b on the UB04 claim form)


UB04 Claim Form



Do not enter any commas, decimals, dashes or spaces

If the values in both of these fields are comprised of greater than 30 percent letters (as opposed to numbers) the provider must contact TMF to obtain an alternate validation code

Patient names cannot be entered due to patient privacy laws

If the provider does not have any claims with either of these fields populated, they must contact TMF to obtain an alternate validation code


PEPPER

Targeted areas were derived from two recent Office of Inspector General (OIG) Reports:

“Inappropriate Payments to Skilled Nursing Facilities cost Medicare more than a Billion Dollars in 2009” (November 2012)

“Questionable Billing by Skilled Nursing Facilities” (December 2010).


Fraud, Waste and Abuse

The Government Accountability Office has designated Medicare as a program at high risk for fraud, waste and abuse

Payments to skilled nursing facilities (SNFs) have been identified as vulnerable to abuse

In 2012 the Office of Inspector General (OIG) found that approximately 25% of SNF claims were billed in error


Compliance

The Office of Inspector General encourages SNFs to develop and implement a compliance program to protect their operations from fraud and abuse

Beginning in 2013, SNFs are required to have a compliance program

As part of a 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


Compliance

The Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide the SNF’s auditing and monitoring activities

There is no “Good” or “Bad” PEPPER

Facility Specific


PEPPER

PEPPER gives provider-specific Medicare data statistics for services vulnerable to improper payments

Allows providers to see how their facility compares to all other SNFs:

Nation

Medicare Administrative Contractor (MAC)

State (MAC only)


State Reference Example

Jurisdiction 5 Wisconsin Physician Services:

Total 2,730

South Carolina 23

Tennessee 79

Texas 27

Utah 12

Virginia 33

Virgin Islands 1

Vermont 2

Washington 101

Wisconsin 14

Virginia 5

Wyoming 6


Claims Data

The SNF PEPPER provides SNFs with their jurisdiction, state and national percentile values for each target area with reportable data for the most recent three fiscal years

FY 2013 (October 1 2012 through September 30th 2013 ) is displayed on the first table

When the target (numerator) count is less than 11 for a target area for a time period, statistics are not displayed


Claims Data

Claim “From Date” and claim “Through Date” fall within the time period of October 1, 2010 through September 30, 2013

Additional claims for June 1, 2010 through September 30, 2010 will be included for episodes of care beginning prior to the reporting period


Target Areas

Therapy RUGs with High ADLs

Nontherapy RUGs with High ADLs

Change of Therapy Assessment

Ultra High RUGs

Therapy RUGs

90+ Day Episodes of Care


Compare Target Report

Page 1 (after introduction)

FY2013 only

When the SNF’s percent is at or above the national 80th percentile for a target area, the SNF’s percent is printed in red bold

When the SNF’s percent is at or below the national 20th percentile for a target area the SNF percent is printed in green italics

When the SNF is not an outlier, the SNF’s percent is printed in black

Blank if Less than 11 SNFs or episodes in group


Target Areas


Target DescriptionTherapy High ADL

Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to RUX, RVX, RHX, RMX, RUC, RVC, RHC, RMC, RLB, to days billed w ithin episodes of care ending in the report period for all therapy RUGs

Nontherapy High ADL

Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to SSC, CC2, CC1, BB2, BB1, PE2, PE1, IB2, IB1 in RUG III; HE2, HE1, LE2, LE1, CE2, CE1, BB2, BB1, PE2, PE1 in RUG IV, to days billed w ithin episodes of care ending in the report period for all nontherapy RUGs


Proportion of assessments w ith AI second digit equal to D w ithin episodes of care ending in the report period, to all assessments w ithin episodes of care ending in the report period

Ultrahigh Therapy RUGs

Proportion of days billed w ithin episodes of care ending in the report period w ith RUG equal to RUX, RUL, RUC, RUB, RUA, to days billed w ithin episodes of care ending in the report period for all therapy RUGs

Therapy RUGs Proportion of days billed w ithin episodes of care ending in the report period for therapy RUGs, to days billed w ithin episodes of care ending in the report period for all therapy and nontherapy RUGs


Proportion of episodes of care ending in the report period at the SNF w ith a length of stay of 90+ days, to all episodes of care ending in the report period at the SNF


Target Count and Percent

Target DescriptionTarget Count Percent

Therapy High ADL


3,833 18.4%

Nontherapy High ADL


119 18.2%



167 6.7%



7,466 35.8%


20,847 97.0%



27 3.2%

Target Count

Number of Episodes of CareShows Volume of Care

The “Target Count” can also be used to help prioritize areas for review

Areas in which a provider is at/above the 80th percentile that have a large target count may be given higher priority than target areas for which a provider is at/above the 80th percentile that have a smaller target count


Percentiles


Target DescriptionTarget Count Percent

SNF National

%ile

SNF Jurisdict.

%ile

SNF State %ile

Therapy High ADL


3,833 18.4% 17.3 12.0 13.6

Nontherapy High ADL


119 18.2% 38.6 32.5 40.2



167 6.7% 15.0 19.0 10.8



7,466 35.8% 27.6 31.9 31.8


20,847 97.0% 77.6 88.2 92.1



27 3.2% 2.4 3.4 1.4

Percentiles

Percentiles are calculated for each of the three comparison groups

State

Medicare Audit Contractor (MAC/FI) jurisdiction

Nation

SNF are to focus on National DataGiven the MAC may potentially use data for Additional Documentation Requests (ADR) reviews, all data is important

SNFs whose target percents are at or above the 80th percentile (i.e., in the top 20 percent) are considered at risk for improper Medicare payments with areas at risk for over coding

SNFs whose target percents are at or below the 20th percentile (i.e., in the bottom 20 percent) are considered at risk for improper Medicare payments with areas at risk for undercoding


A Closer Look at Target Areas


Target DescriptionTherapy High ADL


Nontherapy High ADL










Numerator : Count of days billed within episodes of care ending in the report period for Rehabilitation and Rehabilitation Extensive RUGs

All Rehab “C” or “X” Days

Also includes RLB

Denominator : Count of days billed within episodes of care ending in the report period for all Rehabiliattion RUGs



RUG IV Examples: RUX, RGX, RHX, RMX, RLX,

RUC, RVC, RHC, RMC,

RVX



Numerator : Count of days billed within episodes of care ending in the report period for Nursing RUGs

All Non Therapy “E”Days

Also includes BB1 and BB2 (Low ADL)

Denominator : Count of days billed within episodes of care ending in the report period for all Nursing RUGs



RUG-IV Examples:HE2, HE1

LE2, LE1

CE2, CE1

PE2, PE1

BB2, BB1



Numerator: Count of assessments with AI second digit equal to “D” within episodes of care ending in the report period

“D” is a Change in Therapy Assessment (COT)

Denominator: Count of all assessments within episodes of care ending in the report period

COT initiated October 1st 2011 (FY2012)



Numerator: Count of days billed within episodes of care ending in the report period with RUG equal Rehabilitation Ultra High or Ultra High Extensive (RUC,RUB,RUA,RUX,RUL)

Denominator: Count of days billed within episodes of care ending in the report period for all Rehabilitation RUGs

Not Total RUGs



RUC

RUB

RUA

RUX

RUL


Therapy RUGs

Numerator: Count of days billed within episodes of care ending in the report period for Rehabilitation RUGs

Denominator: Count of days billed within episodes of care ending in the report period for all RUGs


Episode of Care

Based on episodes of care

Defined as a series of claims for a patient where the difference between the “Through Date” of one claim and the “From Date” of the subsequent claim is less than or equal to thirty days

Admission through Discharge

Considered same Episode of Care if readmission to SNF (billed again) within 30 Days of discharge

Data includes episodes of care that end in period reported



Numerator: Count of episodes of care ending in the report period with a length of stay of 90+ days

Denominator: Count of all episodes of care ending in the report period


Target Area Reports

Target area graph provides a visual representation of the SNF’s target area percent over three years

Target Area SNF Data Table titled “Your SNF” includes total number of episodes of care for the target area (numerator) and total (denominator)

Roughly correlates to Patients Episodes

Based on the definition of the target area

Comparative Data for National, State and JurisdictionSome include 80th and 20th Percentile

Some only include 80th percentile

Average Length of Stay for the numerator and for the denominator


Target Area Graph-COT


10/1/10 – 9/30/11 10/1/11 – 9/30/12 10/1/12 – 9/30/13

0%

5%

10%

15%

20%

25%

SNF Natl: 80th %ile Juris: 80th %ile State: 80th %ile

Ta

rge

t P

erc

en

t

Target Area SNF Data


YOUR SNF 10/1/10 – 9/30/11 10/1/11 – 9/30/12 10/1/12 – 9/30/13Target Area Percent 5.94% 6.7%

Target Count (Numerator: count of assessments w ith AI second digit equal to “D” w ithin episodes of care ending in the report period) 150 167

Denominator Count (count of all assessments w ithin episodes of care ending in the report period) 2527 2,506

Note: the COT Assessment

became effective Oct. 1, 2011;

statistics are not available for FY

2011

*Data not available when target count less than 11.

Comparative Data


COMPARATIVE DATANational 80th Percentile 17.1% 19.0%

Jurisdiction 80th Percentile 15.0% 17.2%

State 80th Percentile 14.9% 18.2%0.0%

*Data not available when target count less than 11.

Note: State and/or jurisdiction percentiles are zero if there are fewer than 11 providers with reportable data for the target area in the state and/or jurisdiction.

Comparative Data-FY2013

Target Area

20th Percenti

le

50th Percenti

le

80th Percenti

le

Therapy RUG Days 85.5% 93.2% 97.3%

Ultra High RUG Days 28.1% 53.9% 73.1%

Therapy High ADL Days 20.0% 32.9% 48.1%

Non-Therapy High ADL Days 11.5% 23.4% 42.2

90+ Day Episode of Care 7.5% 14.1% 25.9%Change of Therapy Assessments 7.0% 12.7% 19.0%


Target Area Reports

CMS has developed “suggested interventions” that SNFs may consider when assessing their risk for improper Medicare payments

These are “generalized suggestions and will not apply to all situations”


TMF Suggested Interventions

Nontherapy RUGs With High ADL

High Outliers: This could indicate a risk of potential undercoding of beneficiaries' ADL status. The SNF should determine whether the amount of assistance beneficiaries need with ADL as reported on the MDS is supported and consistent with medical record documentation.



Nontherapy RUGs With High ADL

Low Outliers: This could indicate a risk of potential undercoding of beneficiaries' ADL status. The SNF should determine whether the amount of assistance beneficiaries need with ADL as reported on the MDS is supported and consistent with medical record documentation.



Ultra High

High Outliers: This could indicate that the SNF is improperly billing for therapy services. The SNF should determine whether therapy provided was reasonable and medically necessary, and that the amount of therapy reported on the MDS is supported by documentation in the medical record



Ultra High

Low Outliers: No Suggestions


RUG Reports

SNF Top RUGs Report for all episodes of care lists the top RUGs by number of days

SNF Top RUGs Reports episodes of care with 90+ days lists the top RUGs by number of days

Jurisdiction-wide Top RUGs Reports Report for all episodes of care lists the top RUGs by number of days

Jurisdiction-wide Top RUGs Reports episodes of care with 90+ days lists the top RUGs by number of days


RUG Reports

Each RUG Report IncludesTotal episodes of care in the report period

RUG code and description

Number of RUG days billed

Percent of RUG days to total days

Percent of episodes of care with the RUG billed total episodes of care

Average length of stay for the RUG


Facility Specific Risk Factors

Focus on National Data

Risk Assessment

Review areas approaching or at outliers (80th Percentile, 20th Percentile)

Discuss with the team facility characteristics that may lead to High/Low Utilization target areas

Does the data make sense


Focus on Compliance

Auditing and Monitoring

“The use of audits and/or other risk evaluation techniques to monitor compliance, identify problem areas, and assist in the reduction of identified problems”

Detect

Prevent

Deter



MonitoringCommon Management tool

Determines how effective the controls are

Know what is happening in the field

Day to day reviews

Includes self reviews and peer reviews



AuditingCompleted by someone with no vested interest

Risk Adjusted Selection

Formalized Approach

Established Approach


Focus on Compliance-Education

Education and Training

“The development and implementation of regular, effective education and training programs.”


Focus on Compliance-Education

Easy to understand Focused Education

Risk AreasADL Documentation

Therapy Documentation

Therapy Minutes Accuracy

Nursing Documentation

MDS Accuracy

Billing Accuracy

Compliance with technical and clinical Medicare Requirements


Developing an Action Plan

Oversight of Compliance Officer/Committee

“charged with the responsibility for developing, operating and monitoring the compliance program, and who reports directly to the owner(s), governing body and/or CEO”


RUGs with High ADLs

Therapy and Non-Therapy RUGsAccurate documentation of care provided by Direct care staff

Accurate coding of MDS (Section G) Accuracy of Late Loss ADLs (Bed Mobility, Transfer, Toilet Use and Eating)


RUGs with High ADLs

Direct Care Staff Documentation:Policy and Procedure

ADL documentation forms

Direct care staff ADL education on hire and throughout the year

Competency Assessment

Process for ADL Correction

Auditing and Monitoring activities


RUGs with High ADLs

MDS AccuracyAccuracy of Late Loss ADLs (Bed Mobility, Transfer, Toilet Use and Eating)


MDS Education related to Section G Coding

Practical application of RAI Manual Changes (October 2013 Section G Rules of Three Changes)

Competency Assessment


Therapy RUGs

Therapy and Nursing Documentation to support skilled coverage criteria

Medical necessity of Therapy

Interdisciplinary Review at Medicare Meeting for therapy and nursing clinical criteria

Access to skilled coverage for Nursing

Education related to Medicare Benefit Policy Manual revised Chapter 8 “Coverage of Extended Care (SNF) Services Under Hospital Insurance” implemented January 7th 2014

Minutes Accuracy MDS to Logs

Auditing and monitoring


Presence of Appropriate Documentation

The Medicare Benefit Policy Manual states that “While the presence of appropriate documentation is not, in and of itself, an element of the definition of a “skilled” service, such documentation serves as the means by which a provider would be able to establish, and a Medicare contractor would be able to confirm, that skilled care is, in fact, needed and received in a given case.”


Ultra High RUGs

Provision of clinically appropriate intensity of therapy based on an individualized plan of care

Monitoring Therapy Documentation

Auditing by a non-vested entity

Communication with Contract Therapy

Awareness of unwritten policies that impact compliance

There should not be benchmarks or “rules”

Education related to Medicare Benefit Policy Manual revised Chapter 8 ”Coverage of Extended Care (SNF) Services Under Hospital Insurance” Section (30.2.2.1) titled “Documentation to Support Skilled Care Determinations” implemented January 7th 2014



Accurate and timely completion per Medicare requirements

Resident Assessment Instrument (RAI) Manual Requirements

High Risk of Non-Compliance due to complexity of the regulatory requirements

Therapy Minutes Accuracy

MDS

COT Reviews



Change of Therapy (COT) Review ProcessVerification of Minutes

MDS and Therapy joint responsibility


Timely ARD Selection



Timely Scheduling of Change of Therapy (COT) MDS Assessments

Scheduled on an MDS Within 1 to 2 Days


Awareness of unwritten policies that impact compliance

Facility should not establish benchmarks, scheduling dependent on clinical care provided



Regulatory Requirements for completionAppropriate COT Exceptions

October 1st COT requirement changes practical application

Accurately Combining Assessments

Accurate Billing of Other Medicare Required Assessments (OMRAs)

Auditing and monitoring Correct Billed Days

Process for communicating pending COTs at months end

Education and Training



Provision of clinically appropriate intensity of therapy based on an individualized plan of care

Therapy Documentation to support changes in intensity

Monitoring

Communication with Contract Therapy

Auditing by a non-vested entity

Therapy Staffing to ensure medically necessary therapy is provided per the Plan of Care



Therapy and Nursing Documentation to support skilled coverage criteria

Clinically Appropriate Length of Stay

Interdisciplinary Review at Medicare Meeting for therapy and nursing clinical criteria compliance

Clinically Appropriate Access to skilled coverage for Nursing

Education related to Medicare Benefit Policy Manual revised Chapter 8 ”Coverage of Extended Care (SNF) Services Under Hospital Insurance” implemented January 7th 2014

Auditing and monitoring


Communication

Communicate High Risk Areas to StaffEmployees

Contract Providers

Communicate Plan to ensure compliance

Establish a code of conduct prioritizing compliance

OIG requires “effective line of communication between the compliance officer and all employees, including a process, such as a hotline or other reporting system, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistle blowers from retaliation”


Identification of Non-Compliance

RespondMDS Corrections within 120 Days of Billed Date

Billing Adjustments

Staff Concerns

Investigate all reports of non-compliance

ReportSeek Counsel to determine requirements

Enforcement and Discipline


HHI Analysis

FY 2013 PEPPER ANALYSIS

Harmony Healthcare International (HHI)430 Boston Street, Suite 104, Topsfield, MA 01983

MAC: NHIC

Percentile Ranking

Target Areas Target Count Percent National Jurisdiction

(MAC) State

Therapy High ADL Days 2,730 51.6% 85.30 82.70 83.10Non-Therapy High ADL Days 528 26.7% 58.30 46.10 40.00Change of Therapy Assessments 60 6.9% 19.90 34.00 40.00Ultra High RUG Days 3,097 58.5% 64.60 71.40 69.30Therapy RUG Days 5,292 72.8% 8.80 13.70 15.0090+ Day Episode of Care 19 9.0% 25.90 36.90 32.90

≥ 80th Percentile ≤ 20th Percentile

See Attachment

Therapy RUG Days

Ultra High RUG Days

Therapy High ADL

Days

Non-Therapy

High ADL Days

90+ Day Episode of

Care

Change of Therapy Assess-ments

0%10%20%30%40%50%60%70%80%90%

100%

National Comparative Data

(Actual Percentages)

80th PercentileActual SNF 20th Percentile

Target Areas

Perc

ent

HHI Comparative Data

Actual SNF 20th

Percentile50th

Percentile80th

Percentile

72.8% 85.5% 93.2% 97.3%58.5% 28.1% 53.9% 73.1%51.6% 20.0% 32.9% 48.1%26.7% 11.5% 23.4% 42.2%9.0% 7.5% 14.1% 25.9%6.9% 7.0% 12.7% 19.0%

Non-Therapy High ADL Days

90+ Day Episode of Care

Change of Therapy Assessments

Target Area

Therapy RUG Days

Ultra High RUG Days

Therapy High ADL Days

National Comparative Data-Actual Percentages

HHI Comparative Data

Conclusion

PEPPER is a Tool for Ensuring Compliance with High Risk Areas

Accurate and Appropriate Reimbursement for Care Provided

Compliance is the Foundation for Accurate and Appropriate Reimbursement


Bibliography

Office of Inspector General, U.S. Department of Health and Human Services (OIG) “Inappropriate Payments to Skilled Nursing Facilities cost Medicare more than a Billion Dollars in 2009” (November 2012)

OIG “Questionable Billing by Skilled Nursing Facilities” (December 2010).

PEPPERResources.org

PEPPER HELP Desk: (http://pepperresources.org/HelpContactUs.aspx)

Skilled Nursing Facility Users Guide

http://pepperresources.org/LinkClick.aspx?fileticket=xnGEABk7_dU%3d&tabid=172

UB04 claim form


http://pepperresources.org/HelpContactUs.aspx

http://pepperresources.org/LinkClick.aspx?fileticket=xnGEABk7_dU=&tabid=172

http://pepperresources.org/LinkClick.aspx?fileticket=xnGEABk7_dU=&tabid=172

Questions/Answers

Harmony Healthcare International

(978) 887 - 8919

www.Harmony-Healthcare.com

Connect with Us! @KrisMastrangelo

@CHHRPHart @Harmonyhlthcare

facebook.com/HarmonyHealthcareInternational

linkedin.com/company/harmony-healthcare

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Harmony Healthcare International (HHI)

For attending this seminar, you are eligible for one of the following:

Free PEPPER Analysis

Free RUGS Analysis

Assess your facility against key indicators and national norms.

Contact us at:

[email protected]

Analysis is cost & obligation free

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interpreting your 2014 snf pepper

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