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Medicare Sixth Scope of Work. ? Improve quality of care for beneficiariesQuality improvement projects? Protect Medicare trust fundPayment Error Prevention Program? Protect beneficiaries by addressing individual casesBeneficiary outreach. PEPP Background. ? 1998 OIG Audit - 12.8 billion - improper payments; 25% inpatient hospital PPS? This and other government audits reveal services:Non-coveredInsufficiently documentedMedically unnecessaryIncorrectly coded.
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1. The Payment Error Prevention Program (PEPP)
2. 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
3. PEPP Background ? 1998 OIG Audit - 12.8 billion - improper payments; 25% inpatient hospital PPS
? This and other government audits reveal services:
Non-covered
Insufficiently documented
Medically unnecessary
Incorrectly coded
4. 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
5. 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
6. 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
7. 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
8. 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
9. ? 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., 416 - 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
10. 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
11. ? TMF named Payment Error Prevention Support PRO (PEPSPRO) August 1, 1999. 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
12. ? Development of PEPP resources and tools includes:
General PEPP videotape
PEPP physician documentation videotape
PEPP/Compliance Workbook
Documentation prompter posters/wallet cards
13. ? 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
14. ? 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