Session 3: How to Use and Obtain PHP PEPPER and Helpful Resources

Transcription

1 Session 3: How to Use and Obtain PHP PEPPER and Helpful Resources March, 2015 Kimberly Hrehor

2 Review: How does PEPPER identify Potential Risk? A provider s target area percent is compared to other PHPs percents in the nation, MAC jurisdiction and state. If the PHP s target area percent is at/above the national 80 th percentile it is identified as at risk for improper Medicare payments. Compare and Target Area reports: Red bold print at or above the national 80 th percentile for the target area. 32

3 How to Prioritize PEPPER Findings Use the Compare Targets Report. Consider outlier status compared to: 1. Nation 2. Jurisdiction 3. State Consider Numerator (Target) Count and Sum of Payments. Refer to the target area reports for specifics, changes over time Use Top Diagnoses report to supplement analysis. 33

4 PHP PEPPER User s Guide Documentation of episodes eligible for inclusion Target area numerator and denominator definitions Guidance on how to use PEPPER and how to interpret PEPPER findings Available at PEPPERresources.org in the Partial Hospitalization Program section 34

5 Using PEPPER Coding assess correct coding of principal diagnoses, guide audits Utilization review/quality assess if services are necessary Compliance guide audits for areas at risk Audit results used to develop specific action plans for ensuring compliant documentation, providing education. Consider patient population, external factors To see how other types of providers use PEPPER, visit PEPPERresources.org and click on Testimonials. 35

6 National-level Data National-level data for all PHPs in the nation for the target areas is available at PEPPERresources.org on the Data page (number of numerator/denominator episodes, average length of stay, total payments). Additional reports show percentiles for hospital-based PHPs and CMHC PHPs. 36

7 National-level Data Reports Program for Evaluating Payment

8 How do I obtain my PEPPER? PEPPER is distributed annually in electronic format PEPPER cannot be sent via 38

9 How do I obtain my PEPPER? PHPs administered by Inpatient Psychiatric Facilities or short-term acute care hospitals: PEPPER is distributed via QualityNet to the STACH QualityNet Administrators and those with basic user accounts and the PEPPER recipient role. If there is no QualityNet administrator at your hospital, or if your hospital s QualityNet administrator needs assistance, contact the QualityNet Help Desk at 39

10 How do I obtain my PEPPER? All other PHPs via PEPPER Resources Portal Visit PEPPERresources.org Click on the PEPPER Distribution Get Your PEPPER link Review instructions and access portal Each release of will be available for approximately two years from the original release date 40

11 Required Information to access PEPPER via the PEPPER Resources Portal 6-digit CMS Certification Number (also referred to as the provider number or PTAN) Not the same as the tax ID or NPI number Patient Control Number (form locator 03a) or Medical Record Number (form locator 03b) from claim of traditional fee-for-service Medicare beneficiary receiving services during the specified time period 41

12 Required Information for Portal Access Patient Control Number (form locator 03a) or Medical Record Number (form locator 03b) from claim of traditional fee-for-service Medicare Part A beneficiary receiving services during specified period ( from or through date during that period). 42

13 Now what? Refer to the user s guides. Share internally. Guide auditing and monitoring. Look for increases or decreases, identify root causes. Review medical records. Be proactive and preventive. 43

14 Strategies to Consider. Do Not Panic! Indication of high outlier does not necessarily mean that compliance issues exist. But: Determine Why You are an Outlier Sample claims using same inclusion criteria. Review documentation in medical record. Review claim; was it coded and billed appropriately based upon documentation in medical record? Ensure following best practices, even if not an outlier. 44

15 Who has Access to PEPPER? PEPPER is only available to the individual provider. PEPPER is not publicly available, cannot be released to consultants, etc. TMF does not send PEPPERs to MACs/Recovery Auditors, but does provide them with an Access database that contains the PEPPER statistics for providers in their jurisdiction/region. 45

16 For assistance with PEPPER: Visit PEPPERresources.org for the PEPPER User s Guide and training materials. If you are in need of individual assistance, click on Help/Contact Us, and submit your request through the Help Desk. Complete the form, and a TMF staff member will respond promptly to assist you. Please do not contact your QIO or any other organization/association for assistance with PEPPER. 46

17 Where can I learn more about PEPPER? PEPPERresources.org PEPPER user s guide Recorded training sessions Help Desk Sample PHP PEPPER National data Secure PEPPER Portal 47

18 Pepper Resources website Program for Evaluating Payment 48

19 Feedback on PEPPER We are interested in your comments and suggestions! 49

20 Together, we can make a difference! 50