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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.

Making Time

It’s lonely being a Director of Nursing – doubly so when the agency Administrator is not a nurse.

There are subtle differences between states on the responsibilities of the Director of Nursing but together with the Clinical Supervisor’s role outlined in the Conditions of Participation, it is clear that a DON is responsible for almost everything that happens in a 200-mile radius.  These responsibilities include but are NOT limited to:

  • Oversight of all clinical personnel and all clinical services
  • Making sure that all patients have care plans
  • Patient Assignments
  • Developing and overseeing clinical policies and procedures
  • Infection Control
  • Quality Assurance
  • Staff education
  • Compliance
  • Hiring staff
  • Ensuring that all admission procedures are followed

That’s a pretty daunting list so I hesitate to say it is incomplete but… it is.  Although the tasks can be delegated the responsibility belongs to the DON alone.  Going to a non-clinical administrator about infection control or required education for staff may be a fun way to spend an afternoon but the surveyors will look to the DON for answers.

Before you quit your job and punch yourself in the face for accepting the responsibilities of the DON position, relax.  It can be handled and is handled every day by nurses who are no more skilled than you.

Like most overwhelming jobs, the position of DON is easier when broken down into smaller pieces.  It is also easier if you identify all the impediments to doing your job well before you try to do it better.

Time Management

  • Open Door Policy – this sounds really good in company sound bites and recruiting campaigns but an open door policy can wreak havoc on your day. Instead, hold office hours like college professors do.  This doesn’t mean that nurses cannot interrupt your day for urgent matters but all non-urgent matters should be conducted during office hours.  During office hours, your visitors should have your full undivided attention.  If you want to make notes, wait until after they leave and write down your thoughts while still fresh in your head.
  • Meetings – Meetings are important but after a point, they become time-wasters. Eliminate all meetings that are not necessary and be prepared for necessary meetings.  Meetings should start on time.  Invite participants to arrive a few minutes early if they want to visit with coworkers.  Clinicians who are unprepared at case conference will be obvious.  Don’t rescue them.  After they flounder in front of their peers once or twice, they will be able to fully participate.  Or not.  If an adult cannot be responsible and prepared for meetings, maybe you should rethink their position in your company.
  • Delegation – most tasks of the DON can be delegated. Delegation consists of two parts – one is assigning the task and the other is the oft forgotten follow up.  Survey is a very bad time to find out that a nurse performing utilization review did not understand the process.   Send yourself an email to follow-up on an assignment you delegated.  Was a nurse tasked with collecting data for infection control?  Write it on your calendar to check in with the nurse in a month.  Look at the work done.  This takes a lot less time than trying to recreate data during a survey.   Taking the time to schedule QA, OASIS transmission, annual advisory board meetings and other infrequent but mandated events will reap an enormous return on investment.
  • Set aside some time each day when the phone does not ring in your office. Have the receptionist screen the calls and take messages.  Only take calls from patients who cannot be helped by their nurse, and referral sources.  When this policy was implemented at one agency, about half of all phone calls were handled before they got to the DON.

Hiring Process

 Learn how to interview potential candidates for a job. Listen to what they have to say.  Monster. com has a list of the 100 Most Asked Job Interview Questions. Consider asking candidates to teach you about falls precautions or injecting insulin as if you were a patient.  (Note:  do not ask about what kind of care they drive as suggested on Monster.  Ask what kind of car they dream about owning.  Avoid candidates who name a grey sedan.)

  • Schedule all interviews on the same day and set a mental timer to reduce the amount of time you spend on each interview.
  • In larger agencies, consider deferring the initial interview to a case manager who will be the direct supervisor of the new employee.
  • In all agencies, schedule a second interview that includes various people the candidate will work with on a daily basis. Your current staff is more likely to support a new employee if they endorsed the initial hire.

Staff Education

  • Get someone else to provide education to your staff. Call on drug reps to teach your staff about new and trendy drugs.    Get the wound care folks to teach about wounds.
  • Involve staff by assigning a five to ten-minute presentation on compliant documentation, a new drug or a condition not seen very often in your area to begin each case conference. (Note:  You can start to identify the next case managers or even your replacement by observing how well prepared they are and how comfortable they are talking to their peers.)

Perks of Managers

Setting up your work environment to allow for focus and completion of the tasks and follow-up on coworker’s projects will leave you feeling accomplished. Your stress level will automatically decrease as deadlines are no longer looming over you.  Your ability to trust your staff will improve when you follow-up up on their projects allowing you to appreciate the support you have.   Most importantly, you’ll get home in time for dinner with the fam.

Got any other ideas?  Post in comments!

Episodes and Flu

In today’s lively discussion we will discuss the subtle differences between periods of time referred to as episodes and drive home the reason it matters.

It’s that time again. Most patients who were admitted or recertified to home healthcare this month and for the next several months will have some part of their care delivered after October 1. This is really important to note because any patient who is discharged or transferred to an inpatient facility on or after October 1 will receive some part of their care in the ‘Influenza Vaccine Data Period’. The specific questions about vaccines can be found in the OASIS transfer and discharge assessments beginning with M1041.

M1041 is a trick question. It asks if any part of the ‘episode of care’ include any dates on or between October 1 and March 31. Most veteran home health nurses understand that an episode of care is quite different from an episode which is a 60 day period of time. Newer nurses and therapists may not pick up on the nuances differentiating an Episode of Care from a generic 60 day episode.

An Episode of Care begins at admission OR Resumption of Care and ends at the time of Transfer or Discharge. Got that? As such, an Episode of Care can be equal to a 60 day episode but it could also be longer or shorter than a plan episode.

Let’s take a look, shall we? In the illustrations below, the grey arrows represent generic 60 day episodes. The white boxes will show various events that might occur creating an Episode of Care that is different from a plain episode.

Episode of Care equals generic episode

In the next example, an Episode of Care equals two regular episodes.

2 episodes – 1 Episode of Care

The last example shows how multiple Episodes of Care can occur within one episode. The white squares are one episode of care while the black squares represent the second Episode of Care.

2 Episodes of Care in 60 day episode

Since the actual questions are not asked until transfer or discharge, the challenge is to make the information readily available for the clinician who completes the transfer or discharge OASIS. It is also your challenge if you perform transfers and discharge assessments to make sure you have the information available.

Why is this important?

  1. Many agencies have outcomes posted on Home Health Compare indicating that you really don’t care if your patients get the flu. Or worse – you really want the patient’s to get flu.
  2. Value Based purchasing will likely include information about vaccines. ‘Value Based Purchasing’ means agencies with good numbers will make more money and that money will come from poorly performing agencies. If that doesn’t alarm you, break it down. Do you really want to fund an increase in revenue to your largest competitor who knows how to distinguish between Episodes of Care and generic 60 day episodes?
  3. The flu kills a whole lot of people every year and our elderly are the most vulnerable. While there is concern about the validity of the published numbers, nobody doubts that the flu can take a senior citizen with heart failure out of the game permanently. In 2013, the CDC reports that over 50,000 people died from the flu but last year the number was likely under 5,000. The flu varies wildly and waiting to see how bad it will be does not work.

Most assessment tools in computer software or handwritten, include questions about vaccinations on admission and resumption of care. The problem is getting the information right. The checkboxes are not completely trustworthy without dates.

So, M1041 researches patients on service from Oct. 1 through March 31. It isn’t until M1046 which strangely directly follows M1041 with no mention of 1042, etc. that the clinician is asked if the patient had a flu shot. There are 8 possible responses.

  1. Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)
  2. Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)
  3. Yes; received from another health care provider (for example: physician, pharmacist)
  4. No; patient offered and declined
  5. No; patient assessed and determined to have medical contraindication(s)
  6. No; not indicated – patient does not meet age/condition guidelines for influenza vaccine
  7. No; inability to obtain vaccine due to declared shortage
  8. No; patient did not receive the vaccine due to reasons other than those listed in Responses 4 – 7.

Going back to the second diagram showing how one Episode of Care can go on through discharge over multiple episodes, it is easy to see how the correct response might be hard to find. If you’re really not fond of your coworkers, imagine that it could be you out there doing the discharge and having to click through 200 or so screens to find where a nurse offered the vaccine.

The information reported on Home Health Compare reflects only the number of patients who have received the flu vaccine. If they received it from you during another Episode of care, their physician or any other provider, they obviously go into the mix. What does not get counted are the patients who have been offered and declined the vaccine.

Your numbers should be very close to 75 percent on home health compare. If they are not, there is a really good chance somebody does not understand the differences between an Episode of Care and a 60 day episode.

There it is. Three pages, three unskilled illustrations and almost 100 words so your clinicians will be able to correctly assess whether or not your patients have been vaccinated against the flu. It shouldn’t be this hard, folks. And guess what? We haven’t even touched on Pneumonia or Shingles. Let’s see what washes out in the final regs, first.

Good Luck

Filling in the Gap

Why should you be concerned about the penalties hospitals are facing for readmission? Because in many ways, you are the key to reducing them. A common theme that runs through editorials about rehospitalizations is the powerlessness hospitals and physicians face when discharging patients to the great unknown – home. Here is a great account from an ER physician snagged from the NPR website. Dr. Lena Wen painted a very real picture of the gaping hole between the hospital and the home.

In it, Dr. Wen takes the reader through a typical day in the ER where she works as a physician. She saw a woman with a pain in her gut for years but finally decided to see someone – the ER doc who found that she was depressed and was considering shooting herself with her husband’s gun. She wrote about a ten year old boy who lived in a house with smokers next to an interstate who suffered from asthma. His backpack was home to several expired inhalers and empty pill bottles and candy for lunch. There was an 80 year old woman who had fallen and a gentleman who was detoxing from pain medications. In other words, the doctors and hospital staff are very much aware that much happens in the home that they are not able to address. That should be okay. Home health and hospice workers know even more of the social and economic issues facing patients than the docs do.

Where home health, hospice and our payor sources fall short is in recognizing the value of home health and hospice in mitigating the risks in the home. Strict adherence to Medicare coverage guidelines has narrowed the focus of home health workers to the tasks spelled out on a care plan. A therapist fights for every visit they get. They do not take the time to investigate why a patient might seem to feel ‘blue’. Computer driven documentation is directing care resulting in nurses and aides missing cues to investigate. A patient mentioning they are hungry might mean that it is close to lunch; or it may mean that there isn’t enough food. It shouldn’t require a software prompt to find out but nurses have been conditioned to dread the consequences of an incorrect OASIS response to the extent that they almost never sit back and relax with a patient anymore. That should happen more. Regrettably, it does not.

It may be time to do something different. Maybe the involvement of other resources can help fill in the gap between hospitals and home. I’ll start by providing some contact information for National Organizations that can help you help your patients. You can complete the list with local services. If I were queen of the world, your list would be part of your Emergency Preparedness plan to be reviewed with every patient at the time of admission. Since this hasn’t been happening, it would be a great insert for a Christmas Card plus a part of your Emergency Preparedness plan. By universally distributing and reviewing the list with patients, a door is opened for discussion without intruding in the life of a patient who isn’t ready to disclose ’embarrassing’ facts about their life. It may also be an idea to invite representatives of various local agencies to visit you and your staff so there is no misunderstanding about services provided. Home health aides should be included because they are often the first point of contact when patients share sensitive information. So, click on the links and get to know these National Services and then add your own to it and let me know when you have finished. Just kidding. I’m not in charge of this project. You don’t have to answer to me.

NeedyMeds is a groovy cool website that provides easy access to all the patient assistance programs that might help a patient cover medications. Other ways to save are also offered. So when a patient cannot afford a medication, print the appropriate forms, get the patient’s information and then take it or fax it to the MD for the final touches. When you are at the MD’s office, beg for a few samples to tide your patient over. Each Patient assistance program has different criteria and some medications have more than one program. Go ahead. Think of a drug and try the website.

US Department of Veterans Affairs Many veterans have benefits they have never accessed. An important court ruling in April of this year has determined that the Veterans Administration must assist Veterans who have had problems getting documents from the VA supporting their claims. If there is a reasonable expectation that documents exist and they are not forthcoming by the VA, the ruling will be in favor of the Veteran.

SAMHSA is an often overlooked resource for field nurses. SAMSHA is the Substance Abuse and Mental Health Services Association; part of the US Department of Health and Human Services. Here you can find resources for all kinds of mental health issues including but not limited to drug addiction and alcoholism. If you suspect but are unsure that there is drug use in the household, make sure the information is left in plain view and encourage the patient to call if for no other reason than to be educated about addiction and how to protect himself or herself in their home.

The Suicide Prevention Hotline is available to all. The Elderly account for 12% of our population but 18% of suicides. Veterans commit suicide at an even higher rate. Each community should have their own hotline so look it up and add it to your list.

Elderly Abuse Resources This site provides both training and education for caregivers so they can recognize elderly abuse as well as a way to search for local agencies who investigate suspected abuse.

For your contributions to the list, consider Meals on Wheels, Community food banks, Churches, and local charities that may assist with home maintenance and repairs. There may be some assistance in your community for help with electric and gas bills. If you are the only person a patient sees on a regular basis, consider calling the local park and recreation center and churches about social activities. Isolation can be deadly to an elderly person especially if they are predisposed to depression. If your patient cannot drive (please tell me they cannot drive), call family members or church members and get them a ride. After a few trips to Senior Belly Dancing in Billings, Montana or the free Tai Chi classes in Little Rock, they might be ready to board a bus going to an unknown location where chocolate and Italian food is served. (Is it just me or does this sound a little like Elderly Abuse?)

If working with others in the community to improve patient outcomes doesn’t fit your current job description, you have two choices. The first is to do it anyway and the second is to continue doing what you are doing right up until your agency is purchased by a larger company or goes out of business. The fact is that your patients need more help than a home health agency can provide or hospital can provide and if they don’t get it, they will end up back in the hospital. That should be enough to motivate clinicians but should you have difficulty convincing the folks who might have to pay for a little training, remind them that when the patients go to the hospital, the referrals go to another agency.

Since everybody seems to be feeling the sting of tighter regulatory scrutiny, there has never been a better time to forge new formal and informal relationships with hospitals in your area. That will be much easier if you and your agency are known as the go to source for getting things done for patients. Questions and suggestions always welcome.

Giving Thanks



Wow.  What a challenge.  Thanksgiving is this week and it is only proper that I share with you all the ways we should be thankful.  I’m really struggling.

I could be grateful because I am appealing.  I spend most days at my computer appealing denials for clients.  I enjoy a good argument but the craziness of all these denials for claims for reasonable and necessary care given to eligible patients is overwhelming.  Worse than the financial hit is the overall disrespect of home health and hospice agencies.  If anyone wants to feel like a criminal, all they have to do is work for a home health or hospice. So I may be appealing but I am not grateful.  I would much rather be teaching and doing something – anything – that worked towards better care of patients.  Keep that in mind if you need an inservice or two.

I could be grateful that the Face-to-Face documentation burden has been lightened but I am not.  I guess I’d rather it be lightened than not but I just got ten or so denials this morning related to the requirement.  The Medicare Contractors are going to suck dry the opportunity to withhold money from my clients – and you, too if you do not happen t be a client– until the very last minute.  The regulations taking effect in January have no effect on past denials. 

I could be grateful that more Americans than ever will be able to afford insurance with the ACA but I am not.  The law is so complicated that I think there are only a handful of people who fully understand it and they are not elected officials.  Since nobody really understands it, it has become a dividing line between democrats and republicans who are voting with their party with no idea of how it will play out.  So, no, thank you.  I am not grateful for the ACA.

This doesn’t mean I am not grateful though – even at work.  Home health and hospice have been taken on a ride these past couple of years and you survived. 

I am so very thankful that I know people who are willing to get up and drive to a stranger’s house to adjust pain medications at 3:00 am. 

I know the houses where the water gets cut off for lack of payment located next to the crack house and you find it in you to smile warmly at the patient and show them the same respect that you would if you saw a patient at a $20M Manhattan apartment.

I know your kids are left without a parent during a special football game or school play because you cannot leave a patient in need but I am grateful for the lessen you are teaching to the next generation.  Taking care of others is an important job.  Compassion is a value that should be passed along to the next generation.

I am thankful for those of you who contribute to this blog and The Coders’; even when I don’t agree with you.  I appreciate that you have ideas you are willing to call your own and speak up about them.  You are prime material for patient advocacy.  I like that. 

I love the laughs, the occasional tears and how you make me feel as though I am one of you.  Because I am.

Thank you.

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