CMS Hospice PEPPER Alert

Summary at a Glance

On April 5, 2023, the RELI Group, the CMS contractor for the Program for Evaluating Payment Patterns Electronic Report (PEPPER) released the Q4FY22 Hospice PEPPER. Each Hospice PEPPER summarizes claims data statistics (obtained from paid hospice Medicare UB-04 claims) for the most recent three federal fiscal years (the federal fiscal year spans October 1 through September 30). A hospice is compared to other hospices in three comparison groups:

  • Nation
  • MAC jurisdiction
  • State

These comparisons enable a hospice to determine whether its results differ from other hospices and if it is at risk for improper Medicare payments.

Two new target measures have been added:

  • Average Number of Medicare Part B Claims for Beneficiaries Residing at Home
  • Average Number of Medicare Part B Claims for Beneficiaries Residing in an Assisted Living Facility, Nursing Facility, or Skilled Nursing Facility

The PEPPER contractor describes the reason for adding these two target measures:

Medicare could pay for the same items or services twice if nonhospice items and services are billed to Medicare when they should be covered by hospices. In February 2022, the OIG published “Medicare Payments of $6.6 Billion to Nonhospice Providers Over 10 Years for Items and Services Provided to Hospice Beneficiaries Suggest the Need for Increased Oversight” (A-09-20-03015).

In this report, it is noted that CMS confirmed “its ‘long-standing position [is] that services unrelated to the terminal illness and related conditions should be exceptional, unusual and rare given the comprehensive nature of the services covered under the Medicare hospice benefit’ (84 Fed. Reg. 38484, 38506 [Aug. 6, 2019]). All hospice-related services must be provided directly by the hospice or under arrangements with the hospice (42 CFR §§ 418.64 and 418.70).”

These PEPPER target areas were approved by CMS because they have been identified as being potentially at risk for improper Medicare payments.

DOWNLOAD YOUR HOSPICE PEPPER:

PEPPERs are available via PEPPER Resources Portal and can be accessed by the provider’s Chief Executive Officer, President, Administrator, Compliance Officer, or Quality Assurance/Performance Improvement Officer.