Quality and performance data can be instrumental in improving healthcare, but it’s what you do with that data that matters. Data from the Program for Evaluating Payment Patterns Electronic Report (PEPPER) includes a wealth of information about reimbursement errors, but you should know how to put it to good use in your compliance program.
PEPPER is a benchmarking tool containing hospital-specific data for 14 Diagnosis Related Groups (DRGs) and discharges that have been identified as at high risk for payment errors. The data is provided free of charge by TMF Health Quality Institute, under contract with CMS and is intended to reduce Medicare fee-for-service improper payments. PEPPER used to be distributed to hospitals by their state Medicare Quality Improvement Organization (QIO), but QIOs are no longer involved in providing reports.
Data for different types of providers is released on different dates. TMF will release PEPPER data on several categories, including most hospitals, in April 2017.
(The release schedule and instructions for accessing your hospital’s PEPPER data can be found at this link: http://bit.ly/2m4JAsJ.
More information is available at https://www.pepperresources.org/.)
Make the Most of PEPPER
The PEPPER report is not well understood by some hospital professionals and is not used as much as it could be for quality improvement, says Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, a consulting company based in Shawnee, OK, that assists hospitals with clinical documentation improvement and compliance.
PEPPER data has been a useful resource for several years at Bluegrass Care Navigators in Lexington, KY, which provides palliative, hospice, and other care. The health system has two provider identification numbers, so Bluegrass could pull PEPPER reports on both and compare their performance internally between facilities, as well as to national averages, says Eugenia Smither, RN, BS, CHC, CHP, CHE, corporate compliance officer and vice president of compliance and quality improvement.
When Bluegrass first began using PEPPER data, Smither and her colleagues first took time to validate the data, ensuring it provided an accurate picture of their performance. That is a good practice with any data report on your performance, Smither says, but after a few years of working with PEPPER, they have enough confidence in the report that they forgo that step.
Smither notes that a good feature of the PEPPER report is the clear definition of numerator, denominators, exclusions, and other terms used to analyze the data. (See the story in this issue for concerns about misunderstanding one section of the report.)
Free Up Resources
One benefit of the PEPPER report is that it may provide reassurance that your performance is good enough in one area that it might not need as much compliance oversight as others.
“We were fortunate that we consistently don’t fall into the areas that the contractor identifies as meaning you might need to audit yourselves,” Smither says. “Most healthcare professionals have a lot of administrative duties that they didn’t have before, so if you have an external entity tell you could probably spend less time in this area rather than more, that’s always good. It’s not that we ignore the issue, but we don’t do continuous monitoring in those risk areas because of our scores.”
That allows Smither and her colleagues to spend more time on other issues that need attention. A recent successful performance improvement project on meeting a national patient safety goal from The Joint Commission that involved oxygen safety might never have happened if the PEPPER data hadn’t freed up resources, Smither says.
“We were able to do that project that particular year because when the PEPPER report came out, we scored pretty well,” she says. “It’s the same people who do both work, compliance and quality, so you have to use your resources wisely. If we had been at risk in one of the areas in the PEPPER report, we would have had to address that and try to put an improvement project in place.”
Report Aids Compliance
Providers are missing a big opportunity for quality improvement if they do not use the PEPPER data available to them, Smither says. There is no cost, and it provides a comparison group, along with thresholds for concern.
“It’s a monitoring tool. For compliance, you have to have a plan in place and you have to evaluate where you are,” Smither says. “You have an external benchmarking tool packaged with clear definitions and risk areas already identified for you, and you would be remiss in not using that gift.”
Since all providers must have a compliance plan including certain elements, the PEPPER report can fulfill some of that obligation. One element is monitoring and evaluation, and the PEPPER report gives you both of those components, Smither says.
Some parts of the PEPPER report are less valuable than they were in recent years, Hale notes.
“Some of it is a little past its usefulness, given the changes we’ve seen in the necessity of admission and other issues,” she says. “We have to evaluate some of those data sets a little differently because the report was designed before the two-midnight rule was implemented.”
Dig Deep in PEPPER
To get the most of out the PEPPER data, Smither advises taking your time with it and digging deep.
“I usually read through the whole report one time and then go back to dissect it more in depth. You can’t get everything out of it in the first read,” Smither says. “This is not a report for light reading. It’s a collection of data that you need to analyze.”
Smither also spends time understanding the demographic components of the report, looking at how her patient population compares to that of the state, region, and country. Differences in patient population can shed light on your performance that does not meet the average when compared to those larger areas.
“For example, in southeastern Kentucky, there is not a lot of activity in the assisted living space, whereas nationally it is probably one of the fastest-growing areas,” she says. “Everybody’s population is different, so you have to consider how that affects those risk areas. It’s presented as supplemental information in the report, but it’s helpful when you analyze the report.”
After reading the instructions and definitions, Hale suggests starting with the outlier report. The one-page outlier report is a summary of the data and understanding that first can give you a sense of what portions of the report you should study most closely, she says. (See the story on in this issue for advice on what areas to investigate.)
Remember that the report is data and only highlights areas to investigate, Hale says. Do not assume that just because your PEPPER report has you in the 80th percentile, or even the 20th percentile, that you are making errors with DRG assignment or medical necessity, Hale says. Other factors could be in play.
“If a hospital ranks in the first 1,000, they should get a sense that their risk for audit is relatively high, either from the RAC with DRG accuracy, or the QIO with respect with to medical necessity of admission. That hospital should be particularly attuned to where they score the highest and are at highest risk an audit,” Hale says. “It doesn’t necessarily mean they’re doing anything wrong. It could just be that they’re doing a really good job of clinical documentation improvement and coding accuracy. That 80th percentile ranking might be something to be proud of.”
Low Rank Not Always Good
You won’t know that without internal auditing to make sure coding is accurate, Hale says. She also cautions that a ranking below the 20th percentile isn’t always worthy of celebration. It could indicate that the hospital is being underpaid in that DRG group, necessitating improvement in coding and documentation. Without auditing your operation, you won’t know if you are leaving money on the table.
“I often hear CFOs or compliance officers advise coding or case management that they should have a plan to bring their numbers into the average range. I think that’s an unwise piece of advice,” Hale says. “You want your admissions to be medically necessary, but you’re going to have some short stay admissions. If you try to be average, you might be doing yourself and your patients a disservice.”
Two-day stays data in the PEPPER report should be addressed carefully, Hale says. Two-day stays are now a benchmark of medical necessity, and those cases are not reviewed unless there is evidence of gaming, Hale says. To understand gaming, consider a scenario in which a hospital had been in the 80th percentile for same-day and one-day medical and surgical discharges, then those number dropped sharply and two-day stays increased proportionally.
“It might look like they decided to just keep patients longer. Maybe those patients don’t need to be there and they are keeping them longer to avoid the appearance of an unnecessary admission,” Hale says. “If that kind of thing were to appear in the data, that would be something the hospital definitely should consider.”
Smither developed a dashboard for the organization’s board of directors that provided the highlights of the PEPPER data.
“When you have such detail, the board wants the high-level information,” Smither says. “I wanted them to see the variation among our providers, but also quickly understand where we were at risk and not at risk.”
She used the graphs from the PEPPER report, but also melded that information to graphs with state and national information for comparison. She labeled each graph with a thumbs up or thumbs down. So, in one page they had all the information they needed for that risk area.
“When most compliance people talk to their board, the board is respectful and listen but they don’t get down into the detail. The message I got from board members afterward was that they really liked the thumbs up or thumbs down, because it helped them get the point quickly,” Smither says. “I explained in detail what the risk areas meant and gave them the background they needed, but the most salient points for them were the dashboard with the quick comparison and the thumbs up or down.”
Smither notes that the PEPPER data is not publicly reported, so it is up to individual providers to share that information with others. She urges healthcare providers of all types to share the data so it can be used most effectively for comparisons.
“All providers have risk areas and if there is an opportunity to share this data the way you share other quality data, you should,” Smither says. “The more the data is shared, the more valuable it becomes.”
- Deborah K. Hale, CCS, CCDS, President and CEO, Administrative Consultant Service, Shawnee, OK. Telephone: (405) 878-0118.
Email: [email protected].
- Eugenia Smither, RN, CHC, CHP, CHE, Corporate Compliance Officer and Vice President of Compliance and Quality Improvement, Bluegrass Care Navigators, Lexington, KY. Telephone: (859) 276-5344.
Email: [email protected].
