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Louisiana Health Care
Review
THE MEDICARE
QUALITY IMPROVEMENT ORGANIZATION |
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Hospital Payment Monitoring
Program - HPMP
Formerly known as PEPP - Payment Error
Prevention Program |
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Program Overview
The Centers for Medicare & Medicaid Services (CMS) has
established 2 programs to monitor the accuracy of the
Medicare Fee-for-Service (FFS) program: The Comprehensive
Error Rate Testing (CERT) program and the Hospital Payment
Monitoring Program (HPMP). HPMP monitors PPS inpatient
hospital admissions only. The CERT monitors all other
claims. |
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The HPMP
calculates the error rate for all individual PPS acute care
hospitals nationally based upon the claims reviews conducted
by quality improvement organizations (QIOs). The QIOs are
responsible for monitoring the quality of care, medical
necessity of admissions, and accuracy of Diagnosis Related
Group (DRG) payment related to Medicare inpatient
hospital admissions. The net improper payment amount
- which is calculated by subtracting underpayments from
overpayments for inpatient hospital admissions - in FY 2004
was $3.1 billion dollars of the Medicare Trust Fund (a 3.6%
error rate).
Review &
evaluation of coding, payment and compliance practices tends
to indicate the same inadequacies: lack of information,
inadequate or faulty documentation, and poor communication
between physicians and others involved in the patient’s
episode of care.
It is very important that hospitals understand payment monitoring will continue
through LHCR’s current contract
cycle, 11/01/05 - 10/31/08. |
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HPMP in the
8th Statement of Work
HPMP continues
through LHCR’s current contract cycle, i.e., 8th
Statement of Work, 11-01-05 through 10-31-08. An
additional focus of HPMP efforts this contract cycle is monitoring of Long-Term Acute Care Hospitals (LTACs) in
our state. LHCR and CMS continues to trend and
analyze claims data to determine the focus of HPMP
activities designed to reduce payment errors resulting from
inappropriate utilization, DRG (coding), or billing errors.
LHCR may develop and implement hospital-specific or
statewide improvement projects based on our analytical
findings or CMS may direct LHCR to develop and implement
projects. CMS may also direct us to participate in
nationwide projects.
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As health care regulations change, so will
some of the advice provided here.
We will endeavor to revise these materials as soon as
possible after these changes are disseminated.
It is important that hospitals maintain a system for receiving,
disseminating, and acting on regulatory changes; this will
include updating your compliance program as necessary in
order to achieve your compliance goals.
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The Role of
Hospitals in HPMP
Hospitals
can directly reduce payment errors and support HPMP by
developing, implementing, and maintaining effective:
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utilization management programs and
quality improvement programs
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including effective resource utilization
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prompt attention to opportunities for improvement
and hospital
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and
medical staff education on the causes of payment
errors
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compliance programs, including
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collaboration with compliance officers
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prompt review of PEPPER reports
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identification of inpatient utilization trends and
patterns
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adherence to coding and billing
regulations, including
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The role of
compliance officers is crucial to reducing the incidence of
improper payments, especially those that result from
medically unnecessary services. The HPMP Compliance
Workbook, revised 2005, provides guidance, suggestions, and
tools for hospitals seeking to develop, update, or
strengthen their compliance programs and encourages
hospitals to utilize resources provided by QIOs to support
and enhance their efforts. |
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Some of the following documents are .pdf files and
require Adobe Acrobat Reader. To download, click
here.
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Link to CMS Improper Medicare Fee-for-Service Payments
Report, November 2007 |
The full
version of the FY 2007 report on Improper Medicare
Fee-for-Service Payments. The Improper Medicare
Fee-for-Service Payments Report is a web-based tool that
has been developed to allow users to view the Improper
Medicare FFS Payments Reports online. Each May and
November, the report is published to the public by CMS.
This report is available in the CERT report website
format.
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Link to Appendix for CMS Improper Medicare Fee-for-Service
Payments Report 11/07 |
The data
appendices of the FY 2007 report on Improper Medicare
Fee-for-Service Payments. This report is available in the
CERT report website format. |
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Link to November 2007 CMS Improper Medicare Fee-for-Service
Payments Long Report |
The long version of the
FY 2007 report on Improper Medicare Fee-for-Service
Payments. |
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Link to the User's Guide for the FY
2007 report on Improper Fee-for-Service Payments |
This document is intended to
provide users with instructions on the various features and
functions of the Improper Medicare Fee-for-Service Payments
Report. |
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Prevention of Hospital Payment Errors and Implications for
Case Management |
Link to A
Study of Nine Hospitals with a High Proportion of Short-Term
Admissions.
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"PEPPER - How Hospitals Can Use Comparative Hospital Claims
Data to Prevent Payment Errors" |
Link to PowerPoint presentation
describing the Program for Evaluating Payment Patterns
Electronic Report (PEPPER) |
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"Hospital-Acquired Conditions:
Present-on-Admission Indicator" |
Link to PowerPoint presentation
discussing new Medicare claims requirements. |
"Hospital-Acquired Conditions: Present-on-Admission
Indicator"
Companion
article to above PPT |
Link to MedLearn Matters Article
#5499 |
CMS
Issues Guidance on Emergency Services -
April 26, 2007 |
Link to
a summary of guidance issued to hospitals on emergency
services requirements under the agency’s Conditions of
Participation (CoP), minimum standards which all hospitals
must meet in order to quality for Medicare payments. |
Medicare and
Medicaid Programs;
Hospital Conditions of Participation: Discharge Appeal
Rights -
Final Rule-November 27, 2006 |
Link to
Federal Register listing
containing this final rule which sets forth requirements for
how hospitals must
notify Medicare beneficiaries who are hospital inpatients
about their hospital discharge rights. |
Medicare and
Medicaid Programs;
Hospital Conditions of Participation
Final Rule-November 27, 2006 |
Link to Federal Register
listing
containing the Requirements for History and Physical
Examinations; Authentication of Verbal
Orders; Securing Medications; and Postanesthesia Evaluations |
Medicare and
Medicaid Programs;
Hospital Conditions of Participation: Patients' Rights -
Final Rule-December 8, 2006 |
Link to Federal Register
listing
containing new, updated Requirements for Patients' Rights |
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Recorded PEPPER Training Sessions &
Resources |
Link to Training Resources
provided by the Texas Medical Foundation. |
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OIG Final Supplemental Compliance
Program Guidance for Hospitals |
Supplement
that Updates the OIG guidance published in the PEPP
Compliance Workbook, April 2000.
Source: Texas Medical Foundation, Inc., HPMP QIOSC |
Hospital Payment Monitoring Fact
Sheet:
Physician Care Setting Orders |
Provides
examples of appropriate and inappropriate admission care
setting orders.
Source:
(Medicare Hospital Payment Monitoring Program (HPMP) Compliance
Workbook, April 2000; Medicare Hospital Manual, Chapters 2 &
4) |
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Common Causes of Error |
Discusses the most common causes
of payment errors identified during Sixth Scope of Work (PEPP)
Project Data Collection.)
Source: LHCR’s PEPP project data collection; sixth scope of
work |
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Medicare Guidelines for Appropriate
Use of the Inpatient and Outpatient Observation Care
Settings |
Provides specific information regarding inpatient and
outpatient observation care settings as defined by Medicare
Guidelines.
Source: Medicare Hospital Manual and the PEPP
Compliance Workbook |
Effective Utilization Management
Strategies
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Some of the following documents are .pdf files and
require Adobe Acrobat Reader. To download,
click
here.
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Utilization Review:
Model Admission Flow Chart |
A
step-by-step illustration of the hospital admission process
from 3 entry points with indications for issuance of a
notice of noncoverage, HINN or ABN.
Source: Louisiana Health Care Review, Inc. |
HPMP
Improvement Plan Template
Word Doc
PDF Doc |
A tool for
use in developing and monitoring Improvement Plans provided
by LHCR for hospitals to utilize for assistance in
identifying opportunities for prevention and reduction of
their payment error rates. Source: Louisiana Health Care
Review, Inc. |
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HPMP (PEPP) Compliance Workbook
Link to HPMPResources.org - Updated
March 2008
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ART Data Collection Tool |
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For
more
Quality Improvement
resources, visit
www.medqic.org |
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This Web site is produced by Louisiana Health Care
Review, Inc., the Quality Improvement Organization (QIO) for Louisiana, under
contract 500-99-LA02 with the Centers for Medicare & Medicaid Services (CMS).
The contents presented do not necessarily reflect CMS policy.
If you experience any problems with this
site, please notify us by
e-mail. Thank you.
Louisiana Health Care Review, Inc.
©
2002-2007
8591 United Plaza Boulevard, Suite 270
Baton Rouge, Louisiana 70809
Telephone: 225-926-6353 / Fax: 225-923-0957 |
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