Are You Ready for the SNF PEPPER?

Are You Ready for the SNF PEPPER

Presented by:Elisa Bovee Vice President of

OperationsHarmony Healthcare International, (HHI)

Copyright © 2014 All Rights Reserved 1Harmony Healthcare International, Inc.

Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc.

About Elisa

Elisa Bovee, MS OTR/L

Elisa Bovee is the Vice President of Operations at

Harmony Healthcare International, (HHI)an industry leader in Long Term Care

consulting.

Over 20 years of experience in the long-term care industry

Appeals Coordinator for a National nursing home company

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Objectives

The learner will be able to:State three variables contributing to initiation of the PEPPER in the long-term care settingState the Pepper Target Areas.Describe CMS Comparative Data

Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 3

Are You Ready for the SNF PEPPER

How PEPPER was born;OIG Audits


Wall Street Journal, November 12, 2012

Thomas Burton, November 2012“More intensive services were done than actually performed”“Patients could not benefit from it”“Cutting fraud” Obama


Wall Street Journal

Sample 499 claims by 245 (stays) nursing facilities

1 home reached a settlement agreement on allegations of fraudulent billing for “medically unnecessary” therapy“More therapy during the period on which bills were based”“Look-Back Period”


OIG Report:Claims in 2009

25% billed all claims in error 1.5 billion26% claims not supported in the medical record 542 million in over payment“Majority” error “upcoded”*Many Ultra High

* Original RUG was a higher paying RUG than the revised RUG



20.30%

2.50%

2.10%75.10%

Billing ErrorsIssues found with skilled-nursing facili-ties’ Medicare claims, based on an out-side review of 2009 data

Properly billed

Billed for a more ex-pensive treatment than was provided

Billed for a less expensive treat-ment than was provided

Billed for a condi-tion not covered by Medicare

Source: Department of Health and Human Services Office of Inspector General



Remaining, “downcoded”*Did not meet Medicare coverage requirements

47% claims, misreported information on the MDS“SNF’s commonly misreported therapy”

* If the original RUG was a lower paying RUG than the revised RUG

Harmony Healthcare International, Inc. 9Copyright © 2014 All Rights Reserved

MedPac noted that the payment system “encourages SNF’s to furnish therapy, even when it is of little or no benefit”20062008 SNF’s increasingly billed for higher paying categories even though beneficiary characteristics remained largely unchanged

Harmony Healthcare International, Inc. 10


Copyright © 2014 All Rights Reserved

3 RN Nurses reviewed the claims along with the PT/OT/STAnalysis

UpcodedDowncodedBoth considered errors




Paid $1.5 billion for these claims. This represents 5.6 percent of the $26.9 billion paid to SNFs in 2009 See Table 1 for the percentage of SNF claims that were in error and Appendix D for the confidence intervals



Table 1: Percentage of SNF Claims That Were in Error -

2009


Type of Error Percentage of SNF Claims

Inaccurate RUGs 22.8%

Upcoded 20.3%

Downcoded 2.5%

Did Not Meet Coverage Requirements 2.1%

Total Error Rate 24.9%

Source: OIG analysis of medical record review results, 2012


SNFs billed inaccurate RUGs in 23 percent of claims. Most of these claims were upcoded; far fewer were downcoded. Claims with inaccurate RUGs amounted to a net $1.2 billion in inappropriate Medicare payments



Notably, 20 percent of claims billed by SNFs had higher paying RUGs than were appropriate In these cases, the SNFs upcoded the RUGs on the claims. For approximately half of these claims, SNFs billed for Ultra High Therapy RUGs when they should have billed for lower levels of therapy or nontherapy RUGs



For 57 percent of the upcoded claims, SNFs reported providing more therapy on the MDS than was indicated in the medical record



For a quarter of the upcoded claims, reviewers determined that the amount of therapy indicated in the beneficiaries’ medical records was not reasonable and necessary



For example, in one case, the SNF provided the highest level of therapy to the beneficiary even though the medical record indicated that the physician refused to sign the order for therapy In another example, the SNF provided an excessive amount of therapy to the beneficiary given her condition




In another example, the SNF report on the MDS that speech therapy was provided even though the record contained an evaluation of the beneficiary concluding that no speech therapy was needed and that speech therapy had not been provided




Two percent of SNF claims did not meet Medicare coverage requirements

For some of these claims, beneficiaries were not eligible for SNF care, either because they did not need skilled nursing or therapy on a daily basis or because there were no physician orders for these services




SNFs misreported information on the MDS for 47 percent of claims.

SNFs reported inaccurate information, which was not supported or consistent with the medical record, on a least one MDS item for 47 percent of claimsFor 30 percent of claims, SNFs misreported the amount of therapy that the beneficiaries received or needed




MDS Category With Misreported Information

Percentage of Claims

Therapy (i.e., physical, occupational, speech) 30.3%

Special Care (e.g., intravenous medication, tracheostomy care) 16.8%

Activities of Daily Living (e.g., bed mobility, eating) 6.5%

Oral/Nutritional Status (e.g., parenteral feeding) 4.8%

Skin Conditions and Treatments (e.g., ulcers, wound dressings) 2.4%

Source: OIG analysis of medical record review results, 2012Note: The rows do not sum to 47 percent because some claims had more than on problem


In addition, reviewers found several instances in which SNFs provided more therapy during the look-back period than they did during periods that did not determine payment rates


Look Back Period


In one example, the SNF provided 90 to 110 minutes of therapy a day to the beneficiary during the look-back period; however, after that period, the SNF provided only about half that amount of therapy to the beneficiary


Therapy Minutes


In another example, the SNF provided 50 to 55 minutes of therapy a day to the beneficiary during the look-back period. It lowered the amount to 30 to 40 minutes a day during the rest of the coverage period but then raised it back to 50 to 55 minutes during the next look- back period.


Therapy Minutes


For 17 percent of claims, SNFs misreported whether the beneficiaries received special care. The inaccuracies came primarily from one MDS item in this category – intravenous medication. At the time of our review, SNFs were allowed to report intravenous medication if the beneficiary received it in the hospital prior to or during the SNF stay.Harmony Healthcare International, Inc. 26

MDS


For these claims, the medical records either did not indicate that intravenous medication was provided during the hospital or SNF stay or clearly contradicted that these services were provided


MDS

For 7 percent of claims, SNFs misreported the amount of assistance beneficiaries needed with activities of daily living (e.g., bed mobility, transfers, eating, and toilet use)SNFs also misreported MDS items related to oral and nutritional status and items related to skin conditions and treatments


MDS

SNFs did not always report the correct number of stage of skin ulcers or they reported the presence of burns or open lesions inaccurately. They also did not always correctly report skin treatments, such as surgical wound care or ulcer care.


Skin

Increase and expand reviews of SNF claims

CMS should instruct its contractors to conduct more medical reviews of SNF claims


OIG Recommendations


OIG Recommendations

Use its Fraud Prevention System to Identify SNFs that are Billing for Higher Paying RUGs

CMS should use its Fraud Prevention System to identify and target these SNFs

Monitor Compliance with the New Therapy Assessments

As of October 2011, SNFs must complete a “change of therapy” assessment when the amount of therapy provided no longer reflects the RUG and an “end of therapy” assessment when therapy is discontinued for 3 days


OIG Recommendations

CMS should instruct its MACs and RACs to closely monitor SNFs utilization of these assessments through analyses of claims data. Such analyses will identify SNFs that are using the assessments infrequently or not at all.


OIG Recommendations

Change the Current Method for Determining How Much Therapy is Needed to Ensure Appropriate Payments


OIG Recommendations

CMS should instruct the MACs to provide education to all SNFs, as well as specific training to selected SNFs, to improve the accuracy of their MDS reporting


OIG Recommendations

Follow up on the SNFs That Billed in Error

In a separate memorandum, we will refer to CMS for appropriate action the SNFs with claims in our sample that had inaccurate RUGs or that did not meet coverage requirements


OIG Recommendations

Appendix D: Sample Sizes, Point Estimates, and 95 Percent Confidence Intervals for Estimates Presented in the Report


Characteristic Sample SizePoint

Estimate

95 Percent Confidence

IntervalSNF claims in error in 2009 499 24.9% 19.9%-30.4%

SNF claims with inaccurate RUGs 499 22.8% 18.0%-28.2%

SNF claims with higher paying RUGs than were appropriate (upcoded)

499 20.3% 15.6%-25.6%

Upcoded SNF claims that had an Ultra High RUG 101 48.2% 34.9%-61.7%

Upcoded SNF claims in which SNFs reported providing more therapy on the MDS than was indicated in the medical record

101 56.8% 42.8%-70.2%

Upcoded SNF claims in which reviewers determined that the amount of therapy was not reasonable and necessary

101 25.6% 14.6%-39.4%

SNF claims with lower paying RUGs than were appropriate (downcoded)

499 2.5% 1.3%-4.5%

SNF claims that did not meet Medicare coverage requirements

499 2.1% 0.7%-4.7%

Total inappropriate Medicare payments for SNF claims

499 $1.5 billion $988 million- $2.0 billion

Inappropriate Medicare payments in proportion to total payments to SNFs in 2009

499 5.6% 3.7%-7.6%

Medicare payments for SNF claims with inaccurate RUGs

499 $1.2 billion $736 million- $1.6 billion

SNF claims that had inaccurate information on the MDS

487 47.3% 41.2%-53.5%

Source: Office of Inspector General medical record review, 2012

What is Skilled Care?



Why is this material important?Which team members should be aware of the Medicare Skilled Care criteria?How often will this criteria be relevant to current beneficiaries and applicable for denied claims?


What is Skilled Care? Requires the skills of qualified technical or professional health personnel such as RN, LPN, PT, OT or SLP Must be provided directly by or under the general supervision of a licensed nurse or skilled rehab personnel to assure the safety of the resident and to achieve the medically desired result

“General supervision” requires initial direction and periodic inspection of activity

Ordered by a physicianServices are needed and provided on a daily basis



The need for skilled care must be justified and documented in the medical recordConditions may have prompted the initial hospitalization, but also include the conditions that arose during recovery in the SNF



What is Skilled Care ?

Direct Skilled Nursing ServicesManagement and Evaluation of a Care PlanObservation and AssessmentTeaching and TrainingSkilled Rehabilitation


Skilled Services Categories: Inherent Complexity

Inherent Complexity – Direct skilled nursing services including:

IV feedingIV medsSuctioningTracheostomy CareVentilator supportUlcers


Skilled Services Categories: Inherent Complexity

Inherent ComplexityTube feedingsRespiratory Therapy 7 days per weekSurgical wound or open lesions with treatmentsUnstable clinically with diabetes with injectionsTransfusionsChemotherapyColostomy Care, early post op care


Skilled Services Categories:Skilled Observation and Assessment

Reasonable probability or possibility for complicationPotential for further acute episodesIdentify and Evaluate the need for modification of treatmentEvaluate initiation of additional medical proceduresSkilled observation can be required until the treatment regimen is essentially stabilized



FeverDehydrationSepticemiaPneumoniaNutritional Risk

ChemotherapyWeight lossBlood sugar controlImpaired cognitionSevere Mood and Behavior conditions



Identify and outline daily skilled nursing observations and assessmentsRecord DAILY each itemized area listed on your outline



NeurologicalRespiratoryCardiacCirculatoryPain/Sensation

NutritionalGastrointestinalGenitourinaryMusculoskeletalSkin



A patient with arteriosclerotic heart disease with congestive heart failure requires close observation by skilled nursing personnel for signs of decompensation, abnormal fluid balance, or adverse effects resulting from prescribed medication

Skilled observation is needed to determine when the digitalis dosage should be reviewed or whether other therapeutic measures should be considered, until the patient’s treatment regimen is essentially stabilized Harmony Healthcare International, Inc. 49Copyright © 2014 All Rights Reserved


A patient has been hospitalized following a heart attack. Following treatment but before mobilization, he is transferred to the SNF.

Because it is unknown whether exertion will exacerbate the heart disease, skilled observation is reasonable and necessary as mobilization is initiated and continued until the patient’s treatment regimen is essentially stabilized



A frail 85-year-old man was hospitalized for pneumonia. The infection resolved, but the patient, who had previously maintained adequate nutrition, will not eat or eats poorly.

The patient is transferred to a SNF for monitoring of fluid and nutrient intake and the assessment of the need for tube feeding and assisted feeding if required. Observation and monitoring by skilled nursing personnel of the patient’s oral intake is required to prevent dehydration.


Skilled Services Categories:Skilled Observation and AssessmentA patient left the acute hospital on a high dosage of Coumadin with daily clotting time studies

Assessment and observation is needed until a maintenance dosage is attained and the patient/resident shows no adverse symptoms. Regulation is an integral part of this patient/resident’s coverage. Ongoing observation and assessment, notifying the physician and multiple changes in the plan of care, are also skilled in nature.



If a patient was admitted for skilled observation but did not develop a further acute episode or complication, the skilled observation services still are covered so long as there was reasonable probability for such a complication or further acute episode

“Reasonable probability” means that a potential complication or further acute episode is a likely possibility


Skilled Services Categories:Management and Evaluation of a Care Plan

Based on the Physician’s orders, these services require the involvement of skilled nursing to meet the resident’s

Medical needs Promote recovery Ensure medical safety


This area includes The sum total of unskilled servicesPotential for serious complicationsHigh probability of relapseRecovery and safety Meet medical needs Includes resident’s overall condition





Topic Areas to include:Surgical sitesCirculatory statusStatus of fracturesMaintenance of weight-bearing statusSkin CareLabsConsultant Recommendations


Skilled Services Categories: Management and Evaluation of a Care Plan

Although any of the required services could be performed by a properly instructed person, that person would not have the capability to understand the relationship among the services and their effect on each other. Since the nature of the patient’s condition, his age and his immobility create a high potential for serious complications, such an understanding is essential to assure the patient’s recovery and safety. The management of this plan of care requires skilled nursing personnel until the patient’s treatment regimen is essentially stabilized, even though the individual services involved are supportive in nature and not require skilled nursing personnel.



Example: An aged patient is recovering from pneumonia, is lethargic, is disoriented, has residual chest congestion, is confined to bed as a result of his debilitated condition, and requires restraints at times

To decrease the chest congestion, the physician has prescribed frequent changes in position, coughing and deep breathing. While the residual chest congestion alone would not represent a high risk factor, the patient’s immobility and confusion represent complicating factors when coupled with the chest congestion, could create high probability of a relapse. Harmony Healthcare International, Inc. 58Copyright © 2014 All Rights Reserved

Skilled Services Categories: Teaching and Training

Teaching and Training: Activities which require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen


Skilled Services Categories: Teaching and Training

Colostomy careInsulin administrationProsthesis managementCatheter careG-tube feedings

IV access sites Braces, splints and orthoticsWound dressings and skin treatmentsMedication ManagementOrthopedic Precautions


61

Skilled Rehabilitation

Medicare Benefit Policy ManualOn a daily basisServices rendered are reasonable and necessaryMD orderedPractical matterAn appropriately licensed or certified individual must provide or directly supervise the therapeutic service and coordinate the intervention with nursing services

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Skilled Rehabilitation/MD Involvement

The service must be ordered by a physician.The therapy intervention must relate directly and specifically to an active written treatment regimen established by the physician after any needed consultation with the qualified rehabilitation therapy professional and must be reasonable and necessary to the treatment of the beneficiary’s illness or injury necessary to the treatment of the beneficiary’s illness or injury


63

Skilled Rehabilitation/MD Involvement

MD involvement to prevent injuriesMedicare allows the professional therapist to develop a suggested plan of treatment and to begin providing services based on the plan prior to MD signatureMD signature required before facility bills MedicareMD Faxed signatures acceptable


64

Skilled Rehabilitation Overview

Directly related to a written plan of treatmentRequires knowledge/skills/judgment of qualified professionalServices must be considered under acceptable standards clinical practiceExpectation of improvement of restorative potential in a reasonable and predictable period of time….or….Establishment of a safe and effective maintenance program


65

Basic Criteria for Rehabilitation Services

Must be specifically related to the Physician’s Treatment PlanSkill of a qualified therapist must be neededTreatment plan must expect the patient to improveServices must fall within accepted standards of medical practice and be specific to the patientThe services must be reasonable and necessary


PEPPER Program for Evaluating

Payment Patterns Electronic Report


PEPPER

Compares SNFs to other SNFs nationally2013 Report was received via mail on or about August 30, 2013Envelope with red print on the outside containing your facility specific PEPPERPerceived as Junk mail


Outliers and the Evolution of PEPPER

CMS sees high Medicare expenses as suggestive of over coding CMS asserts 20% highest expenses are questionableCMS identifies expenses above the 80th percentile as outliersCMS asserts that the Bottom 20% of outliers are under coding The bottom 20th percentile as outliers could be perceived as evidence of poor Quality of Care


PEPPER Data

Compare Targets ReportTarget Area ReportsSNF Top RUGs ReportsJurisdiction-wide Top RUGs Reports


PEPPER Data

PEPPER is a Microsoft Excel workbook that can be opened and saved to a PC Per TMF; the report is not intended for use on a network but may be saved to as many PCs as necessary


Where is My PEPPER?

From TMF Health Quality InstitutePEPPERResources.org from the PEPPER HELP Deskhttp://pepperresources.org/HelpContactUs.aspx


http://pepperresources.org/HelpContactUs.aspx

http://pepperresources.org/HelpContactUs.aspx

Where is My PEPPER?


PEPPER ResourcesScroll Down


Skilled Nursing FacilityDistribution Schedule

TMF will distribute PEPPER according to the schedule and methods below.

Annually, on or about May 5 through May 12, 2014 SNFs/swingbeds that are part of a short-term acute care hospital

Electronically via QualityNet secure file exchange


Skilled Nursing FacilityDistribution Schedule

Free-standing SNFs and SNFs that are part of another type of hospital

Available electronically to the SNF’s CEO, president or administrator via secure portal on PEPPERresources.org

Note: SNFs that are part of a critical access hospital will not receive PEPPER.


PEPPER ResourcesResource Manual

Navigate through PEPPER by clicking on the worksheet tabs at the bottom of the screen Each tab is labeled to identify the contents of each worksheet (e.g., Target Area Reports, Compare Targets Report)


Where is My PEPPER?

Effective January 1, 2014 TMF will no longer resend copies of SNF PEPPERs (version Q4FY12) which were initially mailed to all SNFs on August 30, 2013The next SNF PEPPER (version Q4FY13) will be distributed in late April-early May 2014 and will be available for access in electronic format by the SNF’s CEO/administrator/president. TMF will send an email notification when the Q4FY13 SNF PEPPERs are availableTMF encourages you to sign up to receive this email by visiting the Home page of PEPPERresources.org and click on the gray box in the upper right area of the page to “Join the email list….”; fill out the requested information and select the “Skilled Nursing Facility”. This will ensure that you receive any future information/updates pertaining to the SNF PEPPER.


PEPPER

Provider-specific Medicare data statistics for services vulnerable to improper paymentsCompares to all other SNFs across the state, nation or Medicare Audit Contractors(MAC) jurisdictionShared with both Medicare Audit Contractors (MACs) and the Medicare Recovery Auditor Contractors (RACs)


PEPPER

Targeted areas were derived from two recent Office of Inspector General (OIG) Reports:

“Inappropriate Payments to skilled Nursing Facilities Cost Medicare than a Billion Dollars in 2009” (November 2012)“Questionable Billing by Skilled Nursing Facilities” (December 2010)



Claims Data

The SNF PEPPER provides SNFs with their jurisdiction, state and national percentile values for each target area with reportable data for the most recent three fiscal years

When the target (numerator) count is less than 11 for a target area for a time period, statistics are not displayed



Target Areas

Therapy RUGs with High ADLsNon-therapy RUGs with High ADLs Change of Therapy AssessmentUltra High RUGs Therapy RUGs90+ Day Episodes of Care


Compare Targets Report

Each SNF PEPPER summarizes claims data statistics (obtained from paid SNF Medicare UB-04 claims) for SNF episodes of care that end in the most recent three federal fiscal years (the federal fiscal year spans October 1 through September 30)A SNF is compared to other SNFs in three comparison groups:

NationMedicare Administrative Contractor (MAC) jurisdiction and MAC state. These comparisons enable a SNF to determine if its results differ from other SNFs and if it is at risk for improper Medicare payments (i.e., is an “outlier”)


Compare Targets ReportJurisdiction

JE Noridian Healthcare Solutions – 1462 facilitiesJF Noridian Healthcare Solutions – 775J5 Wisconsin Physician Services – 2730J6 National Government Services – 1402JH Novitas Solutions, Inc. – 2454J8 Wisconsin Physician Services – 591J9 First Coast Service Options – 433J10 Cahaba GBA – 761

All Jurisdictions – 15,660



Page 1 (after introduction)FY2012 onlyWhen the SNF’s percent is at or above the national 80th percentile for a target area, the SNF’s percent is printed in red boldWhen the SNF’s percent is at or below the national 20th percentile for a target area the SNF percent is printed in green italicsWhen the SNF is not an outlier, the SNF’s percent is printed in blackBlank if Less than 11 SNFs or episodes in group



Each Target Area listed in the report contains a Comparative Data Table.Identifies the target area percents that are at the 80th and 20th percentiles (for areas at risk for under coding only) for the three comparison groups of nation, jurisdiction and state. The percent values are graphed as trend lines on the Target Area Graph.

State percentiles are zero when there are fewer than 11 SNFs with reportable data for the target area in the state. Jurisdiction percentiles are zero when there are fewer than 11 SNFs with reportable data for the target area in the jurisdiction.


Comparative Data Table

Target Area Reports

PEPPER Target Area Reports display a variety of statistics for each target area summarized over three years. Each report includes

Target area graphTarget area data tableComparative data Interpretive guidance Suggested interventions



Suggested interventions if at/above 80th percentile

ADLsThis could indicate a risk of potential overcoding of beneficiaries’ activities of daily living (ADL) status. The SNF should determine whether the amount of assistance beneficiaries need with ADL as reported on the MDS is supported and consistent with medical record documentation.

Change of TherapyThis could indicate that the SNF is experiencing challenges with delivering services to the beneficiary as anticipated. The SNF may look into factors that lead to the need for the COT assessment (e.g., can care planning be improved? Are there issues with completing therapy as scheduled?)



Suggested interventions if at/above 80th percentile

Ultra High and Therapy RUGsThis could indicate that the SNF is improperly billing for therapy services. The SNF should determine whether therapy provided was reasonable and medically necessary, and that the amount of therapy reported on the MDS is supported by documentation in the medical record.


ADLsTherapy RUG (2011)

RUX Rehabilitation Ultra High / Extensive Services

ADL 11 – 16 RVX Rehabilitation Very High / Extensive Services

ADL 11 – 16 RHX Rehabilitation High / Extensive Services

ADL 11 – 16 RMX Rehabilitation Medium / Extensive Services

ADL 11 - 16

RLX Rehabilitation Low / Extensive Services

ADL 2 – 16RUC Rehabilitation Ultra High with

ADL 11 - 16 RVC Rehabilitation Very High

ADL 11 - 16 RHC Rehabilitation High

ADL 11 – 16 RMC Rehabilitation Medium

ADL 11 – 16 RLB Rehabilitation Low

ADL 11 – 16


ADLsNon-Therapy RUG (2011)

ES3 Extensive Services Tracheostomy Care and Ventilator/respirator

ADL 2 - 16 ES2 Extensive Services Tracheostomy Care or Ventilator/respirator

ADL 2 - 16 ES1 Extensive Services Infection Isolation without Tracheostomy Care or Ventilator/respirator and

ADL 2 – 16 HE2 Special Care High with Depression

ADL 15 – 16 HE1 Special Care High with No Depression and

ADL 15 – 16

LE2 Special Care Low with

Depression ADL 15 – 16

LE1 Special Care Low with No Depression

ADL 15 – 16 CE2 Clinically Complex with Depression

ADL 15 – 16 CE1 Clinically Complex with No Depression

ADL 15 – 16 PE2 Physical Function with ≥2 Restorative Nursing

ADL 15 – 16 PE1 Physical Function with ≤1 Restorative Nursing

ADL 15 – 16



Suggested interventions if at/above 80th percentile90+ Day Episodes of Care

This could indicate that the SNF is continuing treatment beyond the point where those services are necessary. The SNF should review documentation for beneficiary episodes of care with a length of stay of 90+ days to ensure that beneficiaries’ continued care is appropriate and that they received a skilled level of care. The SNF should review plans of care for appropriateness and assess appropriateness of discharge plans.



Suggested interventions if at/below 20th percentile

ADLsThis could indicate a risk of potential undercoding of beneficiaries’ ADL status. The SNF should determine whether the amount of assistance beneficiaries need with ADL as reported on the MDS is supported and consistent with medical record documentation.




Change of Therapy SNFs that are using the COT assessment infrequently or not at all may be targeted by MACs or RACs for review to establish whether therapy assessments are being completed as required (see https://oig.hhs.gov/oei/reports/oei-02-09-00200.asp page 15).


https://oig.hhs.gov/oei/reports/oei-02-09-00200.asp

https://oig.hhs.gov/oei/reports/oei-02-09-00200.asp



Ultra High and Therapy RUGsNot Applicable

90+ Day Episodes of CareNot Applicable


HHI Analysis


HHI Comparative Data


Are You Ready for the SNF PEPPER?

Why is Data Collection and Analysis a MUST?



Compliance, Compliance Compliance



Per CMSThe Office of Inspector General encourages SNFs to develop and implement a compliance program to protect their operations from fraud and abuseBeginning in 2013, SNFs are required to have a compliance programAs part of a compliance program, a SNF should conduct regular audits to ensure services provided are necessary and that charges for Medicare services are correctly documented and billedThe Program for Evaluating Payment Patterns Electronic Report (PEPPER) can help guide the SNF’s auditing and monitoring activities


Compliance Program

Per Federal and State laws and Federal healthcare program requirementsA system of policies and procedures Monitoring and Auditing tools Communication and reporting methodsEnforcementLeadershipCopyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 100

OIG Supplemental Guidance: “Compliance programs help

nursing facilities fulfill their legal duty to provide quality care; to refrain from submitting false or inaccurate claims or cost information to the Federal health care programs; and to avoid engaging in other illegal practices”


Compliance and Ethics Program


OIG Guidance

http://oig/hhs/gov/compliance/complianceguidance/index.asp


Be As Informed As Possible




Compliance Is Mandatory

Medicare/Medicaid Condition of ParticipationMarch 23, 2013 Patient Protection and Affordable Care Act


HIPAA

Privacy RuleSecurity RuleBreach Notification Rule


Penalties: HIPAA

Civil penalties: up to $50,000 per violation ($1.5 Million annual maximum per type of violation)

Criminal penalties: Up to $250,000 and 10 years imprisonment


Efficacy

Criminal sanctions may be mitigated by a compliance program, but only if that program is effective

Most SNFs lack the policies & procedures, staff training, audit functions, and regulatory updates to keep their compliance programs effective

106Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved

Required Compliance Program Components

Written Policies & Procedures, Code of ConductCompliance Officer & Compliance CommitteeTraining and EducationEffective Lines of CommunicationEnforcement of StandardsResponding Promptly to Detected Offenses and Taking Corrective ActionAuditing and Monitoring


Risk Areas

Quality of CareResident RightsBilling & Claims SubmissionEmployee ScreeningKickbacks, Inducements and Self-ReferralsCost ReportingHIPAA Privacy and SecurityRecord Creation and RetentionAnti-SupplementationMedicare Part D


Baseline Audit

Identify risk areasIdentify strengths and weaknessesSeek input from all departmentsAlways be on the lookout for “new” risks


Periodic Audits

Quality of CareResident RightsBilling & Cost ReportingEmployee ScreeningKickbacks, Inducements and Self-ReferralsSubmission of Accurate Claims

HIPAA Privacy and SecurityRecord Creation and RetentionAnti-SupplementationMedicare Part DAdditional risk areas identified in the baseline audit


Annual Review

Annual Review of the overall effectiveness of the compliance program


Compliance Officer

Develop a position descriptionEssential duties

Oversee and monitor the implementation of a corporate compliance programHelp the organization, through policies and procedures, auditing, and training, minimize the risk of fraud and abuse



Compliance Officer

Reports to the Compliance Committee

Directs facility auditsCollect data Develop responsive action plans

Manages compliance hotline reportsCompliance training for the organization


Compliance Officer

Manage employee, officer, contractor, and volunteer screeningOversee HIPAA compliance activityParticipate in the Quality Assurance programConduct annual compliance program review and updateEnsure contractors are aware of your compliance program and resident rights


Compliance Officer

A Compliance Officer can hold another position within the organization at the same time, i.e., staff development coordinator, quality assurance nurseRequires a dynamic person will have to interact with Board members, CNAs, housekeepers, department leaders, contractors, volunteers, and regulators


Compliance Programs

Train and educateProvide compliance training to all employees, officers, directors, owners upon hire and annuallyCreate a training schedule for each risk area


Compliance Programs

Audit and MonitorDevelop audit tools for each risk areaSchedule audits throughout the yearAssign responsibility for auditsDevelop a reporting mechanism for audit results 117Harmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved

Compliance Programs

Review annuallyAcknowledge progressIdentify areas to further advance compliance


Compliance Programs

Stay currentMonitor and incorporate updates into the Compliance Program

New regulationsOIG updatesRecent enforcement actions


Compliance Programs

Compliance Officer is the key to a successful program



Closing Thoughts

There is no “Good” or “Bad” PEPPERCompliance chart auditing at regular intervals for outlier areasAnalyze PEPPER dataDevelop a Compliance Program


Conclusion

Educate, Discuss and PrepareCommunicate to all Staff Medicare Skilled Care Criteria Conduct internal/external Mock Audits to educate staffRefine Interdisciplinary Management of Medicare Additional Documentation Requests


Questions/Answers

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Harmony Healthcare International, Inc.

Follow-up PEPPER Webinar…


Interpreting Your 2014SNF PEPPER

May 9, 2014: 1pm-2:30pm (EST)Speakers: Kris Mastrangelo , OTR/L, LNHA, MBA & Keri Hart, MS-CCC/SLP, RAC-

CT, CHHRP-QT

124

Now that you are ready for your SNF PEPPER, learn how to interpret it during our special follow-up webinarRegister Online: https://www.eventbrite.com/e/interpreting-your-2014-pepper-webinar-tickets-11244501607

https://www.eventbrite.com/e/interpreting-your-2014-pepper-webinar-tickets-11244501607

https://www.eventbrite.com/e/interpreting-your-2014-pepper-webinar-tickets-11244501607


Register online http://info.harmony-healthcare.com/harmony2014

or by phone (978) 887-8919 ext. 13

Register Online

http://info.harmony-healthcare.com/harmony2014

http://info.harmony-healthcare.com/symposium2014/registration

Harmony Healthcare InternationalHave you Considered a Customized Complimentary

HARMONY(HHI) MEDICARE PROGRAM EVALUATION

or CASE MIX ANALYSIS

for your Facility?Perhaps your facility has potential for additional

revenue Assess your facility against key indicators and national

norms

Email us at for more [email protected]

Analysis is cost & obligation freeHarmony Healthcare International, Inc.Copyright © 2014 All Rights Reserved Harmony Healthcare International, Inc. 126

mailto:[email protected]



SNFs can use the Compare Targets Report to help prioritize areas for auditing and monitoringThe Compare Targets Report includes all target areas with reportable data for the most recent year included in PEPPERFor each target area, the Compare Targets Report displays the

SNF’s number of target (numerator) count, Target area percent SNF’s percentiles as compared to the nation, jurisdiction and state comparison groups
