Northeast Health Care Quality Foundation
The QIO for Maine, New Hampshire and Vermont
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QIO TRANSMITTAL SERIES ISSUE: Hospital Payment Monitoring Program - Printable pages The goal of the Hospital Payment Monitoring Program (HPMP) is to help maintain and improve the fiscal integrity of the Medicare program by ensuring correct payments for services furnished by general acute care hospitals under the DRG prospective payment system. Hospitals can find more information about HPMP as well as various tools at www.HPMPResources.org, a national resource for payment error prevention. Medical Record Review Throughout the contract period, a federally-contracted clinical data abstraction center (CDAC) reviews a sample of medical records from each state to identify potential payment errors. The CDAC requests these records directly from the hospitals. Approximately 750 records are requested from each state for this sample each year. After the CDAC completes a screening review, those charts flagged as involving potential utilization, DRG or billing problems are referred to the appropriate QIO for a complete case review. Potential quality of care concerns are also referred to the QIOs. All case specific review for HPMP is performed in accordance with NHCQF review processes and includes physician consultant review as appropriate. Hospitals and/or attending physicians have the opportunity to comment on any potential denials for medically unnecessary admissions or procedures, DRG changes or quality concerns. Cases with confirmed payment errors are submitted to the fiscal intermediary for payment adjustment. The final results of the QIO review are forwarded to CMS to maintain a national database on payment errors. Refer to the DRG Validation, Utilization Review and Quality Review sections of this Transmittal Series for more detailed information on the review process. Data Analysis and Project Development CMS provides each QIO with quarterly hospital specific reports from claims data that allow QIOs to perform outlier monitoring. The reports cover various target areas identified by CMS as potentially at risk for payment errors. The reports provide hospital specific and statewide comparative data for each of the target areas. NHCQF shares the Program for Evaluating Payment Errors Electronic Reports (PEPPER) with the individual hospitals to assist them in performing their own monitoring and auditing of payment patterns. NHCQF also assesses review outcomes to identify any trends potentially indicative of payment errors. If trends are identified through analysis of the claims data and/or review outcomes, NHCQF develops focused projects that are submitted to CMS for approval prior to implementation. If NHCQF suspects that payment errors involve fraud or deliberate abusive attempts to inappropriately enhance reimbursement, NHCQF is contractually required to refer the matter to the Office of the Inspector General for investigation. June 2006 Next Chapter: Utilization Review Process
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