Program for Evaluating Payment Patterns Electronic Reports (PEPPER) is a data analysis report that has been available for hospices since 2012. This report contains claims data statistics based upon UB-04 claims data submissions for a single hospice agency. The statistics are generated for areas that are that are targeted by CMS as at risk for potential of improper Medicare payment. The data is reported in tabular format as well as in graphical format showing a time series of the hospice agency’s performance over time.
What timeframe of data is included in the PEPPER report?
Each PEPPER report summarizes claims data for the most recent three fiscal years (October 1 through September 30).
When is the PEPPER report generated?
The PEPPER report is generated each April. The PEPPER distribution schedule, portal access instructions, and training and resources can be seen here. A PEPPER report is generated for each hospice agency, regardless of whether the agency’s data is concerning or the agency is targeted for additional medical review.
What are PEPPER target areas?
Target areas may change or be added if new areas are identified as target areas for potential risk of improper payment. The report is used by medical reviewers to determine whether a hospice agency should be targeted for additional medical review audits. Hospice PEPPER target areas are the following:
- Live discharges no longer terminally ill: percentage of all hospice patients who were discharged (by death or alive), who were discharged alive excluding patients who were discharged alive due to transfer, revocation, discharge for cause, or patients who moved out of service area
- Live discharges – revocations: percentage of all patients who were discharged (by death or alive) who were discharged alive due to patient revocation
- Live discharges with length of stay between 61-179 days: percentage of all patients who were discharged alive who had a length of stay between 61-179 days
- Long length of stay: percentage of all patients who were discharged (by death or alive) who had a combined length of stay that exceeded 180 days
- Continuous home care provided in assisted living facility: percentage of patients living in assisted living facility for any portion of episode who were discharged (by death or alive) where at least eight hours of continuous care were provided while the patient was in an assisted living facility
- Routing home care provided while patient in assisted living facility: percentage of all routine home care days provided by hospice that were provided while patient was in assisted living facility
- Routing home care provided while patient in nursing facility: percentage of all routine home care days provided by hospice that were provided while patient was in nursing facility
- Routing home care provided while patient in skilled nursing facility: percentage of all routine home care days provided by hospice that were provided while patient was in skilled nursing facility
- Claims with single diagnosis code: percentage of all claims submitted that have a single diagnosis code
- No general inpatient care of continuous home care: percentage of all discharged patients (by death or alive) who had periods of general inpatient care that were longer than five consecutive days
- Average number of Medicare part D claims for beneficiaries residing at home: This metric only includes hospice episodes that are at least three days and that occur at home. For these, the average number of part D claims is computed
- Average number of Medicare part D claims for beneficiaries residing in assisted living facility: This metric only includes hospice episodes that are at least three days and where the patient resides in an assisted living facility. For these, the average number of part D claims is computed
- Average number of Medicare part D claims for beneficiaries residing in a nursing facility: This metric only includes hospice episodes that are at least three days and where the patient resides in a nursing facility. For these, the average number of part D claims is computed
How can a hospice agency use its PEPPER report?
An agency’s PEPPER report contains the agency’s statistics for the target areas as well as comparative statistics: national statistics, state statistics, and MAC jurisdiction statistics. The PEPPER report allows a hospice agency to compare its billing practices to those in its MAC jurisdiction, its state, and across the nation. The PEPPER report also compares the hospice agency’s target values to the national, jurisdictional, and state percentile 80th values for each target area. Agencies that fall above the 80th percentile in any of the target area are considered at risk for improper payment for that risk area. Agencies that score above the 80th percentile in one or multiple target areas will likely be subjects for additional medical review such as TPE, OIG review, or UPIC audit.
- A hospice can use the PEPPER Compare Targets Report to prioritize areas for audit or improvement. The Compare Targets Report reports the hospice agency’s percentile for each target area. A hospice agency can quickly identify if it is at high risk in any target area: if a hospice agency is above the 80th percentile in any target area, the percentile is printed in bold red. Otherwise, all percentiles are printed in black but the agency should check the percentile values. High percentile values (even if below 80) may indicate a potential risk area that the hospice agency should monitor.
- The target area graph shows a bar graph of the hospice agency’s target area value over the three years of data for each of the target areas. The graph also has three trend lines, one for each of the three 80th percentiles for each of the comparison groups. Significant changes in the values over the years should be investigated to be sure that the reason is understood. Is it due to change in staff? Change in management? Change in policies? Or, are there a possibility of improper payments?
- The target area hospice data table contains the various data elements that are used to compute the target area statistic.
- The comparative data table provides the 80th percentile values for the three comparative groups: nation-wide, MAC jurisdiction, and state. The value for any of the comparative groups will be reported as zero if there are fewer than 11 hospices in that group.
How can a hospice agency access its PEPPER report?
PEPPER reports are not sent to hospice agencies. A hospice agency can access its PEPPER report electronically at this website.
Should a hospice access its PEPPER report?
Hospices are encouraged to access their PEPPER reports. The metrics in the PEPPER can support hospice agencies with internal monitoring and auditing. Hospice agencies can use the data to detect trends over time and to compare their performance with that of other agencies – nationally and regionally — to identify outlier behavior and potential anomalies that require further investigation. Reviewing a PEPPER gives a hospice agency the opportunity to improve behaviors or take other corrective actions that can improve the outcome of an audit. It allows a hospice agency to implement self monitoring, self correction, and self improvement which is preferrable to waiting until CMS or a MAC identifies an issue. Additionally, if a hospice is under a large scale audit and has not accessed its PEPPER report, the government may claim that the issues were known or that the agency should have known that it had improper payment practices.