Successful QIO and Hospital Projects through the Payment Error Prevention Program PEPP

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Successful QIO and Hospital Projects through the
Payment Error Prevention Program (PEPP)

• Mitzi Daffron, RN, MS, CPHQ
• AHQA Technical Conference 2003

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Initial PEPP Projects

• 3-day stay prior to discharge to a SNF
• DRG 014 015 (Stroke and TIA)
• DRG 127 (Heart Failure)

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Early Reaction to PEPP

• Fear
• Anger
• Theyre back!
• Bad guys again

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Overcoming a Bad Rap

• PEPP - one big bear trap!
• Bad press
• Negative image in the past
• Grapevine effect
• Bad press

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Moving On

• Education
• Education
• Education!!!

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Types of Education

• Regional workshops
• One-on-One meetings with hospitals and physicians
• CD-Roms
• Print materials
• Videos
• Teleconferences
• Pocket tools and posters

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QIO as a Resource

• QIO can help
• No charge
• Expert consultants in areas of utilization
  review, coding, and documentation
• Available to assist in person, by phone, or by
  e-mail

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Response to Educational Approach

• Positive
• Weve become the not-so-bad guys
• See us as peers
• See us as a resource
• Friends?? - maybe some day!

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First Round of PEPP Projects

• DRGs
• Three-day Qualifying Stay Prior to Discharge to a
  SNF

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Comment

• Results werent dramatic in first round of
  projects

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Lessons Learned

• Face-to-Face meetings with outliers were key
• Dont ask for improvement plans based on claims
  data
• Give feedback on data abstraction - dont wait
  until review is complete
• Although there are more utilization concerns than
  DRG concerns, it is harder to change behavior
  related to utilization
• Physician involvement is essential

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What Worked

• Multi-faceted educational approach
• Being out there with the hospitals and
  physicians - face-to-face on-site and workshops
• Ongoing communication with hospitals - monthly
• Quarterly newsletters updating providers on
  whats happening with the projects, the latest in
  regulations, etc.

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What Hospitals Did

• CFOs met with physicians
• UR staff added in ERs and on floors
• Videos were run in physician lounges 24/7
• Our tools were placed on their web pages
• Data were presented at staff meetings and
  inservices
• Focus on utilization management increased
• Teams, including billing, coding, administration,
  compliance, utilization, and physicians, were
  implemented

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What Worked- KEY

• Hospitals abstracting own data
• Through abstracting their own data, they began to
  see where the problems were, rather than relying
  on the QIOs word
• Proactive implementation of revised processes,
  initiation of teams, etc., to address issues

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Second Round PEPP Projects

• Unnecessary admissions in targeted DRGs
• DRGs 014 and 015 in Kentucky
• DRGs 296 and 182 in Indiana

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Revised Approach

• Keep hospitals informed
• Monitor claims data
• Be available to hospitals and physicians as a
  resource
• Keep it educational!

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Weve Become Warm and Fuzzy, But Did We Improve?

• Admission Necessity in Targeted DRGs
• Decrease in error rate from baseline to
  remeasurement

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DRGs 014 and 015 - Kentucky

• Decrease in error rate

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DRGs 296 and 182 - Indiana

• Decrease in error rate from baseline to
  remeasurement

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Summary - Current Project Preliminary Results

• Significant decrease in error rate
• Better documentation

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HPMP Special Studies

• Kentucky - Hospice
• Indiana - Post-Acute Transfer Policy

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New Interventions

• Coding Video
• Documents on web page for physicians to download
  to PDA
• Hospice guidelines - best practice policy and
  procedure

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Questions?