Skilled Nursing is plagued by inaccurate and inconsistent data. The Medicare claim (UB-04), while imperfect, offers a stable foundation for reimbursement analytics and even allows for cross-provider analysis. CMS uses SNF claim data to identify atypical Medicare billing patterns that reflect areas of potential concern. Specifically, its Program for Evaluating Payment Patterns Electronic Report (“PEPPER”) benchmarks utilization to guide providers through their auditing and monitoring efforts.
The RUG-IV system lacked reimbursement-sensitivity; PEPPER offered little insight beyond a facility’s Ultra High Rehab percentage. Comparatively, PDPM produces thousands of practical composite scores that complicate performance benchmarking. CMS has not quite mastered PEPPER’s PDPM distribution, but the Agency is applying similar data-driven logic per Transmittal 12037, which mandates a 5-Claim Probe and Educate Review of nearly every SNF in the nation, with high-scoring facilities prioritized.
To help Skilled Nursing Facilities gauge their “Reimbursement Risk Profile” at the onset of PDPM, Zimmet Healthcare developed and embedded a proprietary benchmarking algorithm into our z.CORE-Analytics platform. CORE is now part of Netsmart’s Simple suite of applications, but ZHSG continues to update the methodology based on accretive and evolving findings of our Reimbursement-Audit department.
ZHSG’s Statistical Analysis of Likely Targets (SALT) Report is a refined analytical tool for SNF claim benchmarking. SALT quantifies an individual provider’s relative risk under data-driven payment review based on its PDPM claims submitted to Medicare. Like PEPPER, SALT cannot identify the presence of improper payments. Unlike PEPPER’s blunt focus on categorical outlier capture patterns, SALT targets specific reimbursement-drivers within and among the PDPM components most likely to face scrutiny during payment review.
ZHSG has posted SALT Reports on z-INTEL, our data analytics platform, for every Skilled Nursing Facility in the country. Scores are based on claims submitted through September 30, 2022 (2022 Q4 will be added when CMS releases the dataset). CORE users can find their most recent SALT Report for claims submitted through April 2023 in the application’s Benchmarking section. For those not subscribed to z-INTEL or Netsmart’s CORE, z-INTEL will send your facility’s SALT Report upon request.
SALT is one of several ZHSG-defined measures that drive a provider’s Data Profile. For more information about our “z.Data-Defender” initiative, or to discuss how Zimmet Healthcare’s Reimbursement-Audit services can prepare you for CMS’ 5-Claim Review, contact us anytime.
SALT Shaker
Marc Zimmet
PDPM Claim Probe Review:
SALT Sweetens Provider PreparationSkilled Nursing is plagued by inaccurate and inconsistent data. The Medicare claim (UB-04), while imperfect, offers a stable foundation for reimbursement analytics and even allows for cross-provider analysis. CMS uses SNF claim data to identify atypical Medicare billing patterns that reflect areas of potential concern. Specifically, its Program for Evaluating Payment Patterns Electronic Report (“PEPPER”) benchmarks utilization to guide providers through their auditing and monitoring efforts.
The RUG-IV system lacked reimbursement-sensitivity; PEPPER offered little insight beyond a facility’s Ultra High Rehab percentage. Comparatively, PDPM produces thousands of practical composite scores that complicate performance benchmarking. CMS has not quite mastered PEPPER’s PDPM distribution, but the Agency is applying similar data-driven logic per Transmittal 12037, which mandates a 5-Claim Probe and Educate Review of nearly every SNF in the nation, with high-scoring facilities prioritized.
To help Skilled Nursing Facilities gauge their “Reimbursement Risk Profile” at the onset of PDPM, Zimmet Healthcare developed and embedded a proprietary benchmarking algorithm into our z.CORE-Analytics platform. CORE is now part of Netsmart’s Simple suite of applications, but ZHSG continues to update the methodology based on accretive and evolving findings of our Reimbursement-Audit department.
ZHSG’s Statistical Analysis of Likely Targets (SALT) Report is a refined analytical tool for SNF claim benchmarking. SALT quantifies an individual provider’s relative risk under data-driven payment review based on its PDPM claims submitted to Medicare. Like PEPPER, SALT cannot identify the presence of improper payments. Unlike PEPPER’s blunt focus on categorical outlier capture patterns, SALT targets specific reimbursement-drivers within and among the PDPM components most likely to face scrutiny during payment review.
ZHSG has posted SALT Reports on z-INTEL, our data analytics platform, for every Skilled Nursing Facility in the country. Scores are based on claims submitted through September 30, 2022 (2022 Q4 will be added when CMS releases the dataset). CORE users can find their most recent SALT Report for claims submitted through April 2023 in the application’s Benchmarking section. For those not subscribed to z-INTEL or Netsmart’s CORE, z-INTEL will send your facility’s SALT Report upon request.
SALT is one of several ZHSG-defined measures that drive a provider’s Data Profile. For more information about our “z.Data-Defender” initiative, or to discuss how Zimmet Healthcare’s Reimbursement-Audit services can prepare you for CMS’ 5-Claim Review, contact us anytime.