The Payment Error Prevention Program The Payment Error Prevention Program (PEPP)

The Payment Error Prevention Program Medicare Sixth Scope of Work  Improve quality of care for beneficiaries –Quality improvement projects  Protect Medicare trust fund –Payment Error Prevention Program  Protect beneficiaries by addressing individual cases –Beneficiary outreach

The Payment Error Prevention Program PEPP Background  1998 OIG Audit billion - improper payments; 25% inpatient hospital PPS  This and other government audits reveal services: –Non-covered –Insufficiently documented –Medically unnecessary –Incorrectly coded

The Payment Error Prevention Program PEPP Background  Based on audits HCFA has launched broad based initiative  PEPP part of initiative  PROs responsible for implementation  Implementation date varied for PROs –August 1, 1999 –November 1, 1999 –February 1, 2000

The Payment Error Prevention Program PRO Role in PEPP  Since 1984 PROs have monitored: –Medical necessity –Accuracy of DRG payment –Quality of care  In recent years quality improvement added  PEPP is expansion of quality improvement efforts to include improvement of hospital processes related to payment errors

The Payment Error Prevention Program Goal and Focus of PEPP  Reduce national and state payment errors  Limited to hospital inpatient PPS  Focus on: –Medical necessity of admissions –Accuracy of DRG coding –Inappropriate readmissions/transfers –Other billing errors

The Payment Error Prevention Program Implementation/Monitoring of PEPP  Clinical Data Abstraction Centers (CDACs) will: –Screen a random sample of cases –Forward screen failures to PROs  PROs will: –Perform full case review on CDAC screen failures –Notify FI to correct over/underpayments

The Payment Error Prevention Program Implementation/Monitoring of PEPP  PROs will also: –Profile Medicare state-specific data –Request and review/collect data from medical records to confirm potential errors identified through data analysis –Request improvement plans (as appropriate) which would include interventions to be implemented in the hospitals –Provide guidance to hospitals to identify sources of errors and make system changes

The Payment Error Prevention Program  PROs will also: –Implement statewide improvement interventions –Conduct 1st year special projects in areas of unnecessary admissions and miscoded DRGs/other projects as necessary (e.g., septicemia, 079/080 - specified bacterial pneumonia, one-day stays) –Monitor success of all interventions through profiles/data collection/case review –Share remeasurement data with hospitals Implementation/Monitoring of PEPP

The Payment Error Prevention Program Implementation/Monitoring of PEPP  Based on PRO review of random sample, HCFA will calculate national/state payment error rates (including both over and underpayments) for: –Baseline –Ongoing surveillance sample

The Payment Error Prevention Program  TMF named Payment Error Prevention Support PRO (PEPSPRO) August 1, PEPSPRO is responsible for: –Identifying “best practice” interventions for reducing payment errors –Providing PROs consultation on projects, data/analytic advice, compliance expertise –Developing compendium of successful interventions –Maintaining library of analytical techniques –Developing PEPP resources/tools PEPP Support

The Payment Error Prevention Program  Development of PEPP resources and tools includes: –General PEPP videotape –PEPP physician documentation videotape –PEPP/Compliance Workbook –Documentation prompter posters/wallet cards PEPP Resources/Tools

The Payment Error Prevention Program  Assess PEPP coding/utilization risk areas and revise compliance program to meet the goals of PEPP  Perform proactive ongoing analysis of PEPP risk areas through data analysis/audits  Review results of PRO PEPP data profiling/analysis and respond/correct problems/monitor for improvement  Encourage hospitals to participate in PEPP projects developed by local PRO What Compliance Officers Can Do to Support PEPP

The Payment Error Prevention Program  Goal of PEPP is to reduce Medicare payment errors on a national and state level  Compliance officers will be key to the successful achievement of this goal Conclusion