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PEPPER Reports

What if I could tell you how likely you are to find your agency under intense scrutiny by Medicare?  Would you want to know?  What if I could tell you what Medicare expects you to do to address any risk areas?  Would you do it?

Chances are the answer is a resounding, ‘No!’

You can have all this information within 15 minutes.  All you need is your provider number and a patient ID number for a claim that has been paid prior to July 17, 2016.  Both of these numbers are available on any 485.

Using these two numbers, any Medicare certified home health care agency can access the PEPPER portal.  There you will find your agency specific reports that show where an agency falls compared to other agencies in areas that Medicare has identified as those being closely associated with Medicare fraud and abuse.  Of all certified home health agencies, only 20 percent nationwide have bothered to look at their data.

One nurse asked me if maybe it was better not to download reports.  Her rationale was that if Medicare would come down harder if they believed the agency was aware of any high risk areas as opposed to being unaware.  To be clear, Medicare is not going to cut you a break if you didn’t know that your agency was meeting the threshold for any of the target groups reported.

Here’s what the PEPPER reports show:

Average Case Mix

Agencies with an average rate of 1.6 or higher may find themselves looked at for possible up-coding.

Average Number of Episodes    

Nationwide, agencies in the 80th percentile provide an average of 2.78 episodes.  Medicare believes there is a high chance of improper payments if you meet or exceed an average of 2.78 episodes per patient.

5 or 6 Visits                                       

In order to get paid the full amount for an episode, an agency must provide at least five visits.  Any nursing care over and above five visits adds to the cost of the episode but not to the payment.  If your agency has more than 7.2 percent of their episodes with five or six visits, Medicare believes there is a chance that you are maximizing income without regard to patient care.

Non-Lupa Payments                      

Medicare expects that agencies will have LUPA payments.  When the number of LUPA payments is very low, Medicare suspects that an agency is avoiding LUPA costs by providing unnecessary visits to qualify for full payment.

High Therapy                                    

Although some patients require 20 or more therapy visits per episode, the assumption is that agencies in which 2.9 percent or more of patients required 20 or more visits may be adding unnecessary visits to capitalize on the enhanced payment associated with high therapy.


The target for outliers is 7.6 of total payment.  Note that this is less than 7.6 of total episodes.   Anything over 10 percent will be adjusted quarterly.

These indicators of possible improper payments are only data.  It is possible to hit the target in one more areas without doing anything improper.  However, a prudent agency will be well aware of where they fall and document accordingly.  Should questions arise, the agency should be able to provide an explanation as to the aberrancy.  If you cannot arrive at a suitable answer, take a long and hard look at your charts.

The PEPPER reports that have been shared with us do not approach any level of concern.  (Fraudulent agencies often eschew our services which focus on compliance.)  My guess is that PEPPER Reports are effective at identifying improper payments.  Agencies that routinely provide three episodes per patient and all the episodes have exactly 6 visits may not be assessing the patient and meeting their individual needs.   If you are employed by an agency that has hit multiple targets and seems disinterested in addressing them, you may want to reconsider your current employment status.

If you decide to download your PEPPER reports, please let us know.  If you feel like sharing them, we’d love to see them and promise to keep them confidential.

OIG Identifies 5 Characteristics of Home Health Fraud

I am often asked if doing something, usually following the advice of a consultant, might result in a red flag at Medicare.  Most of the time the answer is no.  Medicare is not going to stop everything and go after an agency where nurses mistakenly answered an OASIS question incorrectly if they cancel claims and resubmit corrected versions.  Medicare mines data.  They look for patterns and trends and more importantly, the outliers.  In the past we have seen agencies fall under scrutiny for lengths of stay that far exceed their peers.  We have seen Medicare take a hard cold look at agencies where average payment per patient is high for their area and we know that Medicare will look hard at claims where more than 20 therapy visits are provided.  It’s all about the data.

Medicare has once again been playing in the data fields and has arrived at five new areas of concern.  You should pay attention to these.  Medicare is telling you in advance what they think might be considered fraud.   Read about here or in their own report and then look objectively at your own data.

No recent visit with the supervising physician:  Almost 500 agencies and 16,789 physicians had more than 60 percent of patients on service with no visit billed by the physician in six months.  The good news is that these agencies only constituted 4 percent of all agencies and only 5 percent of physicians met this criterion.  The OIG believes that physicians did not adequately evaluate patients prior to beginning services.  It’s hard to disagree with that conclusion.  If the OIG were to ask, they would be told by us to banish these agencies from the face of the earth and replace them with Ice Cream vendors.

No Hospital or Nursing Home Stay prior to admission.  Get this.  1,751 physicians referred at least 97 percent of their home health patients without a hospital or nursing home stay within the prior 30 days.  Oddly enough, that’s only one half of one percent of physicians and probably the lowest 0.5 percent in their class.  If you have one of these physicians as a referral source, you likely know it or someone higher on the food chain does.  This outlier does not happen without effort and cooperation between both parties.   Remember, home health agencies are not like health clubs.  Patients do not wake up and decide to join a home health agency because they are bored.  Always, no matter what the diagnosis, explain in admission paperwork what happened that precipitated a referral to home health.

Diabetes and Hypertension:  Nationally, the median percentage of patients admitted to a home health agency for diabetes or hypertension is 10 percent.  For about 500 agencies, that number is about 45 percent.   For 7937 physicians, 29 percent or more referrals fell into this category compared to a national median of five percent.  Some areas in the South have remarkably high rates of diabetes and when a small agency has gained the trust of an endocrinologist, the percentage of patients with Diabetes may be quite high. Admit the patients who are eligible and need care and document well.

Multiple Agencies:  770 agencies and 7500 physicians were associated with beneficiaries who had claims billed from multiple agencies over the course of two years.   For the home health agencies, about 26 percent of their patients fit this description compared to the national median of six percent.  For the physicians, the national median was 0 percent and the outliers came in at 14 percent.  This occurs when recruiters or owners of multiple agencies transfer beneficiaries to avoid scrutiny or to meet their own financial needs.

Multiple Admissions:   778 HHAs and 3,822 physicians had or referred patients with a disproportionate number of readmissions for patients.  For these outlier agencies and physicians, about 20 percent of their patients had multiple admissions in a short period of time compared to 6 percent of home health agencies and 4 percent of physicians.  According to their report:

Past OIG fraud investigations have uncovered incidents in which HHAs provided—and physicians supervised—unnecessary care over a long period of time and tried to conceal the duration of that care by periodically discharging and re-enrolling their beneficiaries.

Fraud Hotspots

Now that the OIG has disclosed what they will be looking for, it helps to know where they will be looking. Twenty-seven fraud hotspots in 12 states were identified in the OIG report based on the following criteria:

  • outliers on 2 or more measures,
  • areas with 10 or more HHAs that were outliers on 2 or more measures, or
  • areas with 50 or more physicians that were outliers on 2 or more measures.

Several of the identified hotspots met more than one criteria.  Miami, FL and Detroit, MI met all three criteria.  The combined spending for Medicare Home Health in the 27 hot spots represented 37 percent of home health expenditures nationally.  Note that the OIG has not promised to limit scrutiny to these 27 areas so don’t relax if you live in Montana or Maine.

The 12 states are:fraud hot spots

  • Arizona
  • California
  • Florida
  • Illinois
  • Louisiana
  • Michigan
  • Nevada
  • New York
  • Oklahoma
  • Pennsylvania
  • Texas
  • Utah

If you live in one of these hotspots or if your agency meets any of the five areas considered by the OIG to be characteristic of fraud, it may be time to take a closer look at your Corporate Compliance Plan which should include a clinical record review.  Call if you don’t have one – we can help.  Or, if you believe you cannot afford us, google model compliance plan for home health (if the link doesn’t work).   There is nothing complicated or difficult about a compliance plan.  The only time it gets hard is when an agency has to make hard decisions based upon the information gathered from the plan’s activities.

Keep in mind we know many agencies that have cleaned up after a period where things got out of control usually because leadership became complacent and quit looking.  We also work with agencies who have signed Corporate Integrity Agreements with the OIG.  Compared to Integrity Agreements, compliance plans are a piece of cake.

Comments are always welcome.  You can also email me privately if you have any questions.

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Care for the (whole) Person with Diabetes

A couple of months ago, I contacted Palmetto GBA about the LCD requiring agencies to obtain Hemoglobin A1C’s on diabetic patients every 90 to 120 days.  Included were the ADA guidelines as well as a Medscape continuing education offering that spoke to the dangers of over-testing.  Palmetto agreed to reconsider the current Local Coverage Determination and today, a response was received from Dr. Harry Feliciano MD, MPH – Senior Medical Director of Palmetto GBA.

It seems that Dr. Feliciano read the information I sent and additional research concerning the prevalence of hospitalizations related to hypoglycemia.  He pointed out that the research I sent excluded diabetics who were on insulin and agreed that the current LCD should be updated.

As such, we can expect some changes in late April to be effective in early May regarding Palmetto’s policy regarding A1C’s.  Based on information from Dr. Feliciano, I would expect to see:

Testing reduced to twice yearly for stable diabetic patients who have met their treatment goals. 

Physicians may adjust treatment goals to lessen the risk of hypoglycemia.

Patients receiving insulin will continue to have quarterly A1C testing.

Patients who have their diabetic therapy changed or are not meeting treatment goals should have quarterly A1C’s monitored.

The purpose of requesting a reconsideration was to lessen the risk of denial for patients who are provided care by your agency.  I am not going to insult you by reminding you that you still have to give appropriate care to patients with diabetes.  You already do that, even when documentation is lacking.  But is it enough?  I ask because the incidence of diabetes keeps climbing and the costs are staggering – 245B per year.  If you do the math, 245B is roughly equal to a whole lot of misery for millions of people.  Maybe its time we up our game.

For very good reasons, the OASIS data set and Home Health compare put a premium on diabetic foot care but there is more to good diabetic care than looking at feet.  The following is from the ADA guidelines regarding diabetes and older adults.


  1. Consider the assessment of medical, functional, mental, and social geriatric domains for diabetes management in older adults to provide a framework to determine targets and therapeutic approaches. E
  2. Screening for geriatric syndromes may be appropriate in older adults experiencing limitations in their basic and instrumental activities of daily living, as they may affect diabetes self-management. E
  3. Older adults (>65 years of age) with diabetes should be considered a high priority population for depression screening and treatment. B
  4. Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacological interventions. B
  5. Older adults who are functional and cognitively intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults. E
  6. Glycemic goals for some older adults might reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. E
  7. Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. E
  8. Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. E
  9. When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. E
  10. Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. E
  11. Patients with diabetes residing in long-term care facilities need careful assessment to establish a glycemic goal and to make appropriate choices of glucose lowering agents based on their clinical and functional status. E
  12. Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. E

How many of you ensure that your patients have annual eye exams?  How well and how often do you screen for depression?  Do you run through the PH2 on the OASIS or do you stop and consider each answer carefully in both what is reported to you and what is revealed by other factors?  When was the last time diabetic training for staff was offered at your agency?  If you are visiting a hospice patient, have you adjusted the diabetic regime to provide for comfort as opposed to tight glucose control?

Clinical Record Review

Here are some of the things I see when reviewing records.

  • A patient is taught to drink juice and have a snack when experiencing hypoglycemia.  The same patient is dependent on a walker, has vision loss, moderate to severe pain and is occasionally confused.   Documentation is absent any provisions made for a patient who cannot stroll to the fridge and pour some juice.
  • A patient has a CBG barely over the reporting parameters and the nurse explains it by reporting the patient just ate and took insulin late.  No MD notification. If you think that’s okay, look at the upper parameter.  If it is 150, you might get a pass on patient care but it’s probably double that.  More importantly, surveyors take exception to nurses not following orders.
  • Teaching that complications of diabetes include heart disease, stroke and renal failure to a patient who is on dialysis and suffered a stroke in the post op period following bypass surgery.
  • Patients are scolded when they are discovered eating something that will likely raise their blood sugar such as a donut or jam.  Manners, please.  These patients are our elders and they deserve respect.  Nobody was ever embarrassed to the extent their A1C dropped to below 7.
  • Generic teaching of medications that have very specific and unique side effects.

So maybe the greatest benefit of a relaxed LCD for diabetes is that we can focus our resources on overall better care.  The lowered frequency of A1Cs only applies to stable diabetics with no changes to their treatment but these patients also need eye exams, assessment for depression and emergency teaching for hypoglycemia.  Even if they have been a diabetic for ten years and have been stable for almost as long, make sure they know which medications might cause lactic acidosis and to notify the agency when their activity changes to prevent hypoglycemia.  If you believe that the physician is overly optimistic about your patient’s diabetic goals based on your assessment of the patient in their home environment, respectfully bring it to their attention.

All of these interventions take very little time and can easily be included in care plans when the primary diagnosis is something else.   If we don’t take advantage of ensuring that diabetes is addressed completely when it is not a crisis, the costs – both human and economic – to treat complications will be significantly higher.

To help you get started, her are some resources that may help in developing skills required to assess and treat diabetes.  Please take the time to read one or two and if you find anything that helps your patient care, please share.

Resources for Diabetes

2016 Diabetes Guidelines

2016 Guidelines for Mobile

Lower Extremity Amputation Prevention (LEAP) program

Depression and Diabetes

Coping with Diabetes in Adults

Treatment of Diabetic Ulcers

Diabetic Retinopathy from National Eye Institute

Kidney Disease of Diabetes

Neuropathies in Diabetes

[1] American Diabetes Association. Older adults. Sec. 10. In Standards of Medical Care in Diabetesd2016. Diabetes Care 2016;39(Suppl. 1):S81–S85

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