CMS Issues New Target Area for Hospice PEPPER 

Situation Report | November 9, 2020

The 2021 Hospice Program for Evaluating Payment Patterns Electronic Report (PEPPER), anticipated in the spring of 2021, will include the following new target area: Average Number of Part D Claims per Hospice Episode.

This target area will measure the count of Medicare Part D claims for beneficiaries billed during hospice episodes in the report period as a portion of the count of all beneficiary episodes discharged (by death or alive) by the hospice during the report period (obtained by considering all claims billed for a beneficiary by the hospice). The report period will cover the federal fiscal years 2018, 2019 and 2020.

In August 2019, the Office of Inspector General (OIG) released a report which detailed concerns and improper payments related to Medicare spending outside of the hospice benefit. OIG estimated that the Medicare Part D total cost was $160.8 million for drugs that should have been paid for by hospice organizations. OIG indicates that this is an area of long-standing concern.

It is important for hospices to coordinate with Part D plans and non-hospice providers delivering care or items to hospice beneficiaries. However, hospices must be aware of these other providers. This information is usually not available to the hospice through CMS data systems and, sometimes, patients/families do not make hospice aware when they are seeking services outside of the hospice’s care, creating a condition where items, services and drugs may be incorrectly billed to Medicare.

The additional information slated for next year’s PEPPER is useful to hospices to learn about not just how drugs are being billed for their patients but also how this data compares to other hospices at the state, national and Medicare Administrative Contractor (MAC) jurisdiction.