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.
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.
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.