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The Payment Error Prevention Program PEPP

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Improve quality of care for beneficiaries. Quality improvement projects ... TMF named Payment Error Prevention Support PRO (PEPSPRO) August 1, 1999. ... – PowerPoint PPT presentation

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Title: The Payment Error Prevention Program PEPP


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
Implementation/Monitoring of PEPP
  • ? 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
PEPP Support
  • ? 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
PEPP Resources/Tools
  • ? Development of PEPP resources and tools
    includes
  • General PEPP videotape
  • PEPP physician documentation videotape
  • PEPP/Compliance Workbook
  • Documentation prompter posters/wallet cards

13
What Compliance OfficersCan Do to Support PEPP
  • ? 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
Conclusion
  • ? 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
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