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MetaStar Hospital Payment Monitoring Program (HPMP) Project Kick Off with Hospital Participants


MetaStar Hospital Payment Monitoring Program (HPMP) Project Kick Off with ... Florida QIO completed a similar project in the 7th Statement of Work (SOW) ... – PowerPoint PPT presentation

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Title: MetaStar Hospital Payment Monitoring Program (HPMP) Project Kick Off with Hospital Participants

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MetaStar Hospital Payment Monitoring Program
(HPMP) Project Kick Off with Hospital
  • Reduction of Unnecessary One-Day Stays Through
    Use of a Case Management Protocol
  • Bill French, MBA, RHIA, CPHQ,CPHIT
  • Vice President eHealth Strategies
  • November 16, 2006

Need for the Project
  • 56 of admission denials are one-day stays
  • 76 of admission denials are one- or two-day
  • Wisconsin has the 15th highest ratio of one-day
    stays to all stays in the nation
  • One-day stays account for over 14 of all
    Wisconsin inpatient stays

Wisconsin Ranks High in Specific DRGs
  • DRG 127 (Congestive Heart Failure) 15th
  • DRG 143 (Chest Pain) 12th
  • DRGs 182 183 (GI) 19th
  • DRG 243 (Medical Backs) 6th
  • DRGs 296 297 (Nutritional) 14th

Need for the Project
  • Some Wisconsin Hospitals may be at risk for
    attention by regulatory agencies
  • The project is appropriate regardless of PEPPER
    outlier status for the individual hospital

How Did MetaStar Identify ThisProject Topic?
  • Florida QIO completed a similar project in the
    7th Statement of Work (SOW)
  • Wisconsin Hospitals learned of the project and
    requested MetaStar to consider a case management
    protocol-based project
  • MetaStar HPMP Advisory Group supported project

Objectives of the Florida (QIO) Project
  • Decrease the number of inappropriate inpatient
  • Assist physicians in identifying the appropriate
    care setting
  • Assist hospitals in decreasing Medicare admission

Inappropriate Inpatient AdmissionsResulted From
  • Lack of documentation by physicians to support
    medical necessity for inpatient admission
  • Physician lack of knowledge and understanding of
    the hospital admission criteria

Floridas Case Management (CM) Protocol
  • Based on the assumption that Case Managers and
    Utilization Management Personnel are proficient
    in the use of admission criteria
  • Admissions based on case management protocol
    would provide more accurate assignment of
    inpatient admission status

Floridas Case Management (CM) Protocol (cont.)
  • Physician order to admit patient per Case
    Management Protocol when inpatient is not the
    obvious care setting
  • Two to six hour hold status during which time CM
    assess the patient
  • CM assigns patient to appropriate status
  • Decision upheld by ordering physician

Design of Florida Project
  • Identified intervention group of 20 hospitals to
    utilize the CM protocol
  • Control group of similar hospitals not utilizing
    the CM model

Results of Florida Project
  • The relative reduction in admission denial rate
    was three times greater for the protocol group as
    the control group
  • Positive correlation between positive improvement
    and relative frequency of use of the protocol
  • Protocol used in 30 of admissions

MetaStar Experience With PreviousOne-Day Stay
  • Focused on discussions with MetaStars Physician
    Consultant and Hospital Medical Staff
  • Discussions were generally favorable but it was
    difficult to engage a large number of physicians

Wisconsin Experience With PreviousOne-Day Stay
  • Hospitals utilizing a case management model more
    accurately assigned the correct patient
  • Involvement of the physician in the case
    management process resulted in more accurate
    assignment of patient classification

Two Phase Project
  • Phase One Volunteer group of hospitals (PPS and
    CAH) develop and pilot protocols
  • Phase Two High Outlier PPS hospitals not
    participating in Phase One
  • Baseline and re-measurement will be accomplished
    in both phases

Phase One
  • All hospitals regardless of outlier status will
    be invited to participate
  • Develop and pilot case management protocols
  • Employ case management protocols at the hospital
    level - if appropriate

Phase Two
  • Identified group of one-day stay high outlier PPS
  • Will require a quality improvement plan from the

Project Indicators
  • Percent of one-day stays to all stays
  • Gross payment error rates
  • Number of Wisconsin PPS hospitals utilizing a
    case management protocol at the beginning of the
    project compared to conclusion of the project

Expectation of Participants
  • Attend Webinars, calls and other events
  • Consider use of a case management protocol
  • Include appropriate hospital and medical staff on
    the project
  • Assist MetaStar in baseline and re-measurement

MetaStars Role
  • Work with individual hospitals or groups of
    hospitals to develop a case management protocol
    appropriate for the hospital
  • Communicate with the Fiscal Intermediary and
    other agencies
  • Sponsor educational events
  • Assist in overcoming barriers

Project Goals
  • Relative reduction of one-day stays by 3
  • Reduction of 458 unnecessary one-day stays
  • 50 of PPS hospitals adopt a case management

Benefits of Participation
  • Feedback/education on CM process from MetaStar
    and other participants
  • Strengthen Compliance Program
  • Assist in communication with physicians/medical

Benefits of Participation (cont.)
  • Assistance with overcoming barriers
  • Sharing of best practices
  • Benefit from previous successful project
    conducted in other states
  • Coordination with Fiscal Intermediary

Project Timeline
  • Determine baseline data December 2006 through
    January 2007
  • Develop and implement Case Management Protocol
    January 2007 through March 2007
  • Implement and utilize protocols April 2007
    through August 2007
  • Determine re-measurement and sustain improvements
    September 2007 through November 2007

Next Steps
  • Participants sign/decline Confidentiality
    Agreements to work as part of a group
  • Gather questions, barriers, concerns to be
    addressed by MetaStar
  • Determine where hospitals are in the Case
    Management Protocol process

A Word About PEPPER
  • Program for Evaluating Payment Patterns
    Electronic Report (PEPPER)
  • Provide trended data on how hospitals compare to
    other hospitals in the state
  • Provide trended data on how individual states
    compare to the nation
  • Provided quarterly to hospitals via QNet

PEPPERs (cont.)
  • PEPPERs available on QNet for a period of seven
  • Hospital has to request report if not uploaded in
    seven days
  • 67 of hospitals open report in seven days

MetaStar Team
  • Bill French, MBA, RHIA, CPHQ, CPHIT
  • Vice President eHealth Strategies
  • Kim Horton, RHIT, CCS, CPHQ
  • Coding/UR Consultant
  • Candi Davis, RHIA, CPHQ
  • Coding/UR Consultant
  • Eric Streicher, MD
  • Medical Director
  • Jennifer Parisi
  • Administrative Assistant

Contact Information
  • MetaStar, Inc.
  • 2909 Landmark Place
  • Madison, WI 53713
  • (608) 274-1940
  • This material was prepared by MetaStar under
    contract with the Centers for Medicare Medicaid
    Services (CMS), an agency of the U.S. Department
    of Health and Human Services. The contents
    presented do not necessarily reflect CMS policy. 
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