New Tool Available for HHAs to Assess Risk for Improper Medicare Payments
Tuesday, March 31, 2015
by: Visiting Nurse Associations of America

Section: Public Policy and Advocacy




Beginning July 2015, Home Health Agencies (HHAs) will have a free new tool available to help them assess their risk for improper Medicare payments. TMF ® Health Quality Institute is developing a new Program for Evaluating Payment Patterns Electronic Report (PEPPER) for HHAs under contract with the Centers for Medicare and Medicaid Services (CMS).

What is PEPPER?

PEPPER is an educational tool available to providers to help them proactively monitor their claims and work to prevent improper Medicare payments. PEPPER summarizes an HHA's Medicare claims data in areas that may be at risk for improper Medicare payments. It compares the HHA's statistics with aggregate statistics for the nation, Medicare Administrative Contractor (MAC) jurisdiction and the state. If a provider's statistics are at/above the national 80 th percentile the provider is identified as an "outlier" and may be at risk for improper Medicare payments. PEPPER cannot identify the presence of improper payments.

As the regulatory focus on improper Medicare payments becomes more intense for HHAs, this free comparative data report can help providers identify when their billing statistics differ from most other HHAs for these six target areas:

TARGET AREA

TARGET AREA DEFINITION

Average Case Mix

N: sum of case mix weight for all episodes paid to the HHA during the report period, excluding LUPAs and PEPs

D: count of episodes paid to the HHA during the report period, excluding LUPAs and PEPs

Average Number of Episodes

N : count of episodes paid to the HHA during the report period

D : count of beneficiaries served by the HHA during the report period

Episodes with 5 or 6 Visits

N : count of episodes with 5 or 6 visits paid to the HHA during the report period

D : count of episodes paid to the HHA during the report period

Non-LUPA Payments

N : count of episodes paid to the HHA that did not have a LUPA payment during the report period

D : count of episodes paid to the HHA during the report period

High Therapy Utilization Episodes

N : count of episodes with 20+ therapy visits paid to the HHA during the report period (first digit of HHRG equal to '5')

D : count of episodes paid to the HHA during the report period

Outlier Payments

N: dollar amount of outlier payments received by the HHA during the report period

D: dollar amount of total payments received by the HHA during the report period

 

When will the HHA PEPPER be released?

The HHA PEPPER is currently under development. TMF anticipates the reports will be available to providers in July, 2015 through the PEPPER Resources Portal.

How can I learn more?

A HHA PEPPER user's guide will be made available on the PEPPERresources.org website in June, 2015 in the section for Home Health Agencies. TMF will conduct web-based training sessions to help providers understand their report. Join the email list at PEPPERresources.org to receive notifications of training opportunities and report distribution.

PEPPER is distributed by TMF under contract with the Centers for Medicare & Medicaid Services. Visit PEPPERresources.org to access more information on PEPPER.

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