Last month, CMS held a Webinar along with their contractor, TMF Health Quality Institute, to introduce the new Program for Evaluation Payment Patterns Electronic Reports (PEPPER) for Home Health Care starting in July 2015.
Like with Hospice, SNF and other Post Acute Care (PAC) providers, TMF and CMS offer these annual reports as an educational tool to help them proactively monitor their claims and work to prevent improper Medicare payments.
It is interesting to see how CMS is leveling the playing field among the PAC providers with changes like the new IMPACT Quality Measures, Star Ratings, and CAHPS Hospice, among others. There will be six target areas in the home health PEPPER reports as defined in the table below:
|Home Health PEPPER Report Target Areas|
|Outlier Payments||Percent outlier payments received to total payments received|
|Average Number of Episodes||Episodes paid to count of beneficiaries served|
|Average Case Mix||Sum of case mix for all non-LUPA/PEP episodes paid to count of non-LUPA/PEP episodes|
|Episodes with 5 or 6 Visits||Count of episodes paid with 5 or 6 visits to count of all episodes paid|
|Non-LUPA Payments||Count of episodes paid that were not a LUPA to count of all episodes paid|
|High Therapy Utilization Episodes||Count of episodes with 20+ therapy visits paid to count of episodes paid|
Additionally PEPPER will include two “top” reports:
1. Top diagnoses for episodes in the most recent year
2. Top diagnoses for therapy episodes (early/late 0 -13, early/late 14-19, 20+)
PEPPER will be reported in 12 - month periods for the previous three calendar years, with the oldest time period rolling off as the new time period is added each year. The reports will compare the provider’s data to aggregate statistics for the nation,
Medicare Administrative Contractor (MAC) jurisdiction and the state. It was noted in the webinar that if a provider’s statistics are at/above the national 80th or at/below the 20th percentile, the provider is identified as an “outlier” and may be at risk for improper Medicare payments.
CMS has already curtailed 3 of the 6 targeted measures (outliers, case mix, therapy case weights) through regulations and has been commenting on the variations of home health utilization across the country for years. It is notable to see the average number of episodes against beneficiary counts as one of the target areas. With Value Based Purchasing (VBP) on the horizon, I could imagine total payments per beneficiary as an economic “efficiency” measure down the road, especially when compared to outcomes. Now that’s real pay for performance.