The U.S. Department of Health and Human Services' Office of Inspector General (OIG) plans to review compliance with the home health prospective payment system to determine whether home health agency (HHA) claims were paid in accordance with federal laws and regulations. A prior OIG report found that one in four HHAs had questionable billing. Since 2010, nearly $1 billion in improper Medicare payments and fraud has been identified relating to the home health benefit. PEPPER, which is sponsored by the Centers for Medicare & Medicaid Services (CMS), is a provider-specific Medicare data report that summarizes a provider's Medicare claims data for services identified as vulnerable to improper payments. The new PEPPER for HHAs released in July summarizes statistics for these six target areas:
- Average case mix
- Average number of episodes
- Episodes with five or six visits
- Non-LUPA payments
- High therapy utilization episodes
- Outlier payments
PEPPER can support an agency's compliance efforts by identifying where it is an outlier for these target areas. It is an opportunity for all HHAs to self-monitor their billing practices, compare their activities with other HHAs across the nation and determine whether they are an outlier in their practices and possible subjects of special review by the OIG.
How Can I Obtain My PEPPER?
The Chief Executive Officer, President, Administrator or Compliance Officer of the agency should:
- Review the Secure PEPPER Access Guide
- Review the instructions and obtain the information required to authenticate access.A medical record number or patient control number from a claim for services with a "from" or "through" date between Dec. 1 - 31, 2014 will be required for access.
- Visit the PEPPER Resources Portal
- Complete all the fields
- Download your PEPPER
Note: Some HHAs have stated that the patient control number (PCN) that they obtained from the UB04 claim form for a traditional, Medicare fee-for-service beneficiary with a "from" or "through" date between December 1-31, 2014 was very different from the claim number TMF obtained from the paid claims database. TMF has researched this issue in coordination with CMS and Medicare Administrative Contractor (MAC) staff and has reached out to HHAs that did not have trouble accessing their PEPPER.
TMF learned that:
- The MAC does not change the PCN; they process the claim as it was received from the HHA or from the vendor authorized to transmit claims on behalf of the provider.
- Some billing software/vendors use the beneficiary health insurance claim number (HICN or Medicare number) as the patient control number. TMF has determined that only 0.25% of the patient control numbers TMF obtained from the paid claims database are formatted as an HICN.
Therefore, TMF suggests that HHAs *not* use a PCN that is the same as the beneficiary HICN to access their PEPPER. Instead, we recommend using the remittance advice received from the MAC to obtain a patient control number; select a PCN for a claim with a "from" or "through" date between December 1 - 31, 2014. This *may* be a nine-digit number that starts with 16, 17, 18 or 19.
If you still have difficulty, please contact us via the Help Desk for assistance.
How can I learn more?
Recorded PEPPER training sessions are available on the Home Health Agency Training and Resources Page at PEPPERresources.org , along with the HHA PEPPER User's Guide. Join the email list at PEPPERresources.org to receive notifications of upcoming training opportunities and report distribution.
PEPPER is distributed by TMF® Health Quality Institute under contract with the Centers for Medicare & Medicaid Services. Visit PEPPERresources.org to access more information on PEPPER. If you have questions or comments about PEPPER or need help obtaining your report, visit our Help Desk to request assistance.