Federal regulators have suspended a key tool used by some nursing homes for internal auditing, but experts cautioned providers not to let the stoppage hinder their compliance efforts.
The Centers for Medicare & Medicaid Services said last month that it was pausing its PEPPER reports, which show nursing homes how they’re trending on metrics often tied to payment irregulartities. PEPPER stands for Program for Evaluating Payment Patterns Electronic Report, and, in nursing homes, the program reports how often and to what extent facilities are billing traditional Medicare for key therapy and nursing services and how long they’re keeping patients in-house.
The report metrics were last updated after the rollout of the Patient Driven Payment Model. CMS said in its announcement that it would use the next several months to review the indicators it tracks to improve the reporting system “and enhance the quality and accessibility of the reports.”
While some updates would be welcome, providers can’t wait until they’re enacted in fall to resume tracking their billing and care practices, according to Renee Kinder, executive vice president of clinical services at Broad River Rehab.
“All of the data that CMS has is our data. So it’s about knowing that relationship between your overall claims that you’re submitting and if it is supported by the medical record,” Kinder told McKnight’s Long-Term Care News Monday. “That is the largest difference that we see between RUGS and PDPM is that there’s this element of clinical specificity that needs to be documented in alignment with the MDS to receive the appropriate reimbursement.”
She suggested providers use sampling to review practices periodically and ensure that all elements of care and billing are aligned.
“For everything that you’re coding and billing, can you walk that back to the medical record?” she asked “And where are our opportunities to do better? As a therapist, I’m always thinking about the care, but not just how we could document it better. Did we miss anything medically about this patient that we could have better identified to help them to improve in a more appropriate way?”
PEPPER trepidation
Skilled nursing PEPPERs are usually released in April. In some years, fewer than 50% of providers downloaded their reports to check how they were performing against peers regionally or nationally or simply to monitor them for internal concerns or potential improvements. Stephanie Kessler, a healthcare consulting partner with Pennsylvania advisory firm RKL, said some nursing homes failed to do so because they had relatively few Medicare patients or weren’t aware that the reports existed.
Kinder said the fact that CMS painted them as a tool that could indicate billing irregularities — but not necessarily so — also led to confusion among providers, who are used to the agency taking a more black-and-white approach with reporting.
But PEPPER reports’ ability to help with risk mitigation can make it a valuable tool, Kessler told McKnight’s.
“By effectively utilizing PEPPER reports, SNFs can proactively identify areas for improvement, enhance compliance, and optimize their billing practices in alignment with Medicare guidelines,” she said. “Regular monitoring and proactive measures can contribute to improved overall performance and a commitment to providing high-quality care.”
CMS said it would issue a request for information to better understand how the program might better serve providers. Kinder predicted revisions would incorporate more metrics tied to CMS focus areas, including health equity, social determinants of health and discharge planning. Kessler, meanwhile, said providers could benefit by having access to updated reports that incorporate real-time data more than once a year.
Monitor individually
Both experts also encouraged providers to use the pause to strengthen their own efforts to monitor trends in building activity and coding patterns.
“A robust compliance program, whether internal or external, can help mitigate risks during the ‘PEPPER Pause,’” Kessler said. “This may involve conducting clinical record and claim audits, along with implementing a thorough triple-check process before submitting claims for payment.”
While some vendors may provide methods to help track billing trends versus a national sample, Kinder said it’s most important that providers understand their own practices before looking for comparisons.
“On occasion we’ll get so caught up in where we fall in the mix with everyone else that we don’t look internally,” Kinder said. “People get so caught up in looking at other folks and where they fall in the trendline that they forget to actually look at their own practices. Maybe you have patients that look very different from the SNF down the road, so your trends should look different. Don’t try to look the same as everyone else. Just do right by the patients that you’re serving.”
