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CMS: Hospital Payment Monitoring Program Cheat Sheet (DRAFT) by [deleted]

This is a draft cheat sheet. It is a work in progress and is not finished yet.

WHAT IS HPMP?

The Hospital Payment Monitoring Program (HPMP) is a nationwide effort by the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services, to protect the Medicare Trust Fund by ensuring that Medicare pays for services that are reasonable and medically necessary.

To ensure that services are reasonable and medically necessary, Primaris will continue to perform full case review on the hospital medical records sampled monthly by the Clinical Data Abstra­ction Center (CDAC). The data from those reviews, along with other data available from CMS, will be analyzed for patterns of payment error. Primaris may implement hospital or topic specific rapid-­cycle quality improv­ement projects based on the findings.

HPMP PURPOSE & GOAL

Under CMS contract requir­ements, Primaris’ HPMP project task is to measure, monitor, and reduce the incidence of improper fee-fo­r-s­ervice inpatient payments, including errors in: DRG coding; provision of medically necessary services; and approp­ria­teness of setting, billing, and prepayment denials. Reducing such errors will, in turn, protect the Medicare Trust Fund.

Primaris will analyze data received from CMS such as the Program for Evaluating Payment Patterns Electronic Reports (PEPPER), Medicare claims and Missouri payment errors to identify patterns and trends among Missouri hospitals. If proble­matic areas are identi­fied, Primaris will collab­orate with hospitals to identify causes and develop interv­entions to prevent these payment errors.

The long-term goal of HPMP is to help hospitals prevent payment errors through data analysis, focused audits, and the implem­ent­ation of system changes that will ensure payment accuracy. Primaris provides data, education and assistance to hospitals to meet this goal.
 

HPMP

ROLE OF HOSPITALS

Primaris recommends that hospitals monitor for payment error patterns through effective compliance programs that address coding, billing and medical necessity issues. An effective compliance program is crucial to reducing incidence of improper payments, especially those that result from medically unnece­ssary services. Compliance monitoring can be supported by the ongoing review of quarterly PEPPER data from Primaris. This report assists hospitals in identi­fying trends based on inpatient discharge data that may lead to payment errors. New processes should be implem­ented, or existing processes revisited, for areas identified as needing improv­ement.

About Primaris

Primaris is a healthcare consulting firm that works with hospitals, physicians and nursing homes to drive better health outcomes, improved patient experi­ences and reduced costs.