Billing And Compliance Success Through PEPPER (Program For Evaluating Payment Patterns Electronic Report)


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Course Description

Compliance standards are paramount in all healthcare settings. Auditing and monitoring Medicare utilization is a demanding process. The Compliance Officer, CEO and President are responsible for assuring the team utilizes all tools available to adhere to the regulatory guidelines governing their site. Additionally, balancing organizational success and quality care is equally as challenging. This program will illuminate the advantages of using the PEPPER tool to maintain compliance and provide direction for potential quality care issues.

Assessing compliance and financial success coupled with accurate payment from the government is at the forefront for healthcare Providers. The government provides the PEPPER (Program for Evaluating Payment Patterns Electronic Report) tool for Providers allowing multiple advantages for oversight of the internal Medicare program. This report is an analysis of key data points associated with billing, DRG coding and admission necessity issues. Analysis of this data is critical for prioritizing focus areas for audit, maintaining proper documentation and submission of accurate bills to Medicare.

The CEO, CFO, Compliance Officer as well as Utilization Review must understand this report and employ the data points to manage high risk behavior and minimize improper payments from Medicare.

Join this program to hear how the management team can expand on analysis of facility specific data that the government is tracking and comparing to state, national and jurisdiction competitors.

This program will elaborate on the PEPPER tool, distributed by the government to assist providers in auditing and monitoring Medicare program activities. The PEPPER data is reviewed by the Medicare Contractors as well as other governmental fraud detectors to identify outliers leading to potential fraud and abuse of the Medicare program. This tool is distributed annually with Provider specific data for each entity. The data shares how the organization measures up to entities across the country as well as in their respective state and Contractor jurisdiction. Locating, understanding and making the most of this valuable data will allow providers to achieve success on many levels. Learn how to develop internal tools that will track the data prior to the posting of the PEPPER. How this confidential report can lead Officers to offenses and aid in developing corrective action will be addressed. The government is clear in their intent for locating key indicators in provider data that could lead to further record reviews and investigations. This course will illuminate how management can educate staff to have heightened understanding of the elements in this report and the impact on service delivery. The identification of changes in billing, coding problems and a rise in length of stay can help Administration achieve the goal of preventing improper payment. The course will outline how to interpret and use the PEPPER to full advantage.

Areas Covered In The Session:

  • Review of the data statistics identified by CMS as at high risk for improper payment
  • Identifying areas of potential overpayments and underpayments
  • How to prioritize areas for compliance auditing and monitoring
  • The billing activity tracked over time and the comparison with other hospitals or facilities
  • Review of hospital or facility-specific data and the comparative target area statistics for the state,
    jurisdiction, and nation
  • How to identify changes in billing practices and Medicare reimbursement for CMS target areas
  • Keys to monitoring readmission rates to identify opportunities for improvement related to case management, discharge planning and quality of care
  • Comparing length of stay data to length of stay data for the jurisdiction
  • Medicare reimbursement for target areas, track and trend over time
  • Improving medical record documentation
  • Coding compliance auditing and monitoring
  • Conducting regular audits to ensure that medical necessity for admission and treatment is documented and
    that bills submitted for Medicare services are correct

Learning Objectives:

  • Attendees will be able to state the PEPPER Target Areas
  • Attendees will be able to identify organizational-specific risk factors for Medicare reviews
  • Attendees will be able to state 2 strategies to address risks and maintain Medicare compliance through data
    analysis and auditing
  • Leaders will be able to identify a plan for hospital/facility action regarding PEPPER Data
  • Leaders will be able to utilize strategies for maintaining a current compliance program utilizing PEPPER

Who Should Attend:

  • CEOs and Administrators
  • Chief Financial Officers
  • Compliance Officers
  • Nurse Managers
  • Utilization Review/Quality Improvement Staff
  • Health Information Management Staff
  • Rehabilitation Directors

About Our Speaker:

Elisa Bovee has been working in the healthcare environment advocating for patients through education and clinical guidance for over 20 years. With a Masters degree in Occupational Therapy she has managed a national operations team performing audits and analysis across the US for skilled nursing and healthcare providers. Her expertise includes Compliance Programs, Regulatory guidelines, development of Education programs, Reimbursement and skilled documentation for nursing and therapy professionals. Managing claims through the Development Request and Denial phases is Ms. Bovee’s forte. Elisa presents programs nationally targeting all interdisciplinary groups seeking guidance and clarity on a multitude of Regulatory and clinical topics. Elisa has written and contributed to articles for numerous national trade publications.


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