The 8th Scope of Work: What Providers Can Expect

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The 8th Scope of WorkWhat Providers Can Expect

• Kimberly Hrehor, MHA, RHIA, CHE
• Marianne Lundgren, RHIA, CCS
• Texas Medical Foundation
• June 6, 2005

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Who is TMF?

• Under contract with the Centers for Medicare
  Medicaid Services (CMS), perform as the Quality
  Improvement Organization (QIO) for Texas
• Contract to conduct quality and peer review for
  various entities, the Vaccines for Children
  program with the Texas Department of State Health
  Services, similar programs for Hawaii and
  Delaware
• Experts in quality improvement, data collection,
  review activities

3
The 8th Scope of Work Contract with CMS

• Begins August 1, 2005
• Assisting Providers Develop Capacity to Achieve
  Excellence through Transformational Change
• Nursing Home, Home Health, Hospital, Critical
  Access/Rural Hospital, Physician Practice,
  Physician Practice Underserved Populations,
  Physician Practice Pharmacy Benefit (Part D)
• Protecting Beneficiaries and the Medicare Program
• Beneficiary Protection, Hospital Payment
  Monitoring Program

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Nursing Home Quality Improvement (QI)

• 1,144 nursing homes in Texas TMF is expected to
  work with 15 (172)
• Three focus areas
• Clinical performance measure
• High Risk Pressure Ulcers, Physical Restraints,
  Management of depressive symptoms, Management of
  pain in chronic residents (optional)
• Process improvement (setting targets for clinical
  measures)
• Organizational change (person-centered
  care/culture change from medical to social model)

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Home Health QI

• Will work with an identified participant group
  to
• Reduce acute care hospitalization
• Improve pain interfering with activity
• Improve dyspnea
• Improve management of oral medications

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Hospital QI

• Goal is to achieve transformational change
• Initiatives include
• Increase number of hospitals voluntarily
  reporting on the Hospital Quality Alliance
  measures
• Assure all data reported are valid, timely, and
  complete
• Notice! Hospitals must submit the records
  requested by the CDAC within a specific timeframe
  to be validated. If hospitals do not submit
  records, their validation score is impacted, and
  if hospitals do not pass validation it affects
  their annual Medicare payment update.
• Improve performance on 3 surgical care
  improvement project measures

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Hospital QI, cont.

• TMF will work with identified participant groups
  to
• Improving performance on appropriate care
  measures
• Acute myocardial infarction
• Heart failure
• Pneumonia
• Surgical complications improvement project
• Systems improvement and organizational change

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Critical Access/Rural Hospital QI

• Recruit and assist CAHs in reporting data in
  rural performance measures
• Assist CAHs in improving performance on 1
  reported measures
• Conduct staff climate survey and patient safety
  checklist

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Critical Access/Rural Hospital QI, cont.

• First QI initiative specific to CAHs
• QI measures applicable to CAHs
• National database to capture CAH data
• Anticipated additional CAH QI requirements
• CAH focus areas
• Acute myocardial infarction, heart failure,
  pneumonia, emergency department transfer
  communication, patient safety, health information
  technology

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Physician Practice QI

• Diabetes, mammography, adult immunizations
• Doctors Office Quality Information Technology
  (DOQ-IT)
• Initiative to promote the adoption of electronic
  health record systems and IT in physician offices
  to enhance access to patient information,
  decision support to improve care for Medicare
  patients in clinical areas

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Physician Practice Underserved Populations QI

• Goal is to improve quality of care to Medicare
  underserved racial/ethnic populations
  (African-American, Asian Pacific Islander,
  American Indian/Alaskan Native, and/or
  Hispanic/Latino)
• TMF will focus on African/American and
  Hispanic/Latino by
• Working with a group of identified physician
  office participants to improve the quality of
  primary care
• Promoting cultural competency among providers of
  services
• Improving clinical performance measures in areas
  of diabetes, mammography, and adult immunizations

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Physician PracticePharmacy Benefit (Part D) QI

• Part D benefit will be effective Jan. 1, 2006 for
  all Medicare beneficiaries
• QIOs will implement quality improvement projects
  starting August 1, 2006
• Goal is to improve the safety of dispensing
  prescription drugs and to improve prescribing
  derived from evidence-based guidelines
• TMF will provide assistance to
• Physician practices
• Pharmacists
• Prescription DRG Plans (PDPs), including Medicare
  Advantage organizations

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Beneficiary Protection

• Case Review Activity (no changes from 7th SOW)
• Quality of Care Admission Necessity DRG
  Assignment
• Emergency Medical Treatment and Labor Act
  (EMTALA)
• Referrals from carriers, FIs, other contractors
• Hospital requests for higher-weighted DRG
• Outlier review
• Reviews for Hospital Payment Monitoring Program
• Beneficiary Complaints

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Hospital Case Review Process

• Complete review on required cases (retrospective)
• Issue notices to physicians/hospitals
• Admission denials
• DRG changes
• Quality issues
• Evaluate additional information submitted
• Notify fiscal intermediary of payment adjustments
  needed (denials and DRG changes)

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Medicare BeneficiaryComplaint Process

• Receive beneficiary complaints for all care
  settings (via helpline)
• Conduct quality case review
• If appropriate, coordinate mediation
• Inform beneficiary of review outcome
• New when no quality concerns are identified,
  there will be some alternative approaches,
  similar to mediation, that will be available to
  help resolve issues between physicians and
  patients

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Mediation

• Form of conflict resolution
• Brings 2 parties together with neutral mediator
• Option for resolution of complaint when
• Standards of medical practice met
• Communication problems existed
• Beneficiary had unrealistic expectations
  resulting in perception of poor care
• Other advantages in mediating

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Hospital Payment Monitoring Program (HPMP)

• Purpose of HPMP is to measure, monitor, and
  reduce the incidence of improper fee-for-service
  inpatient payments
• HPMP will continue in the 8th SOW with some
  additional activities
• All QIOs will be required to either conduct an
  HPMP project (a focused intervention involving a
  specific area prone to payment errors and/or
  specific hospitals) or justify why they do not
  need to conduct one.
• LTCHs will become a focus for reducing payment
  errors, as QIOs will be asked to monitor LTCH
  data and they may conduct an HPMP project
  involving LTCHs.

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Hospital Payment Monitoring Program (HPMP), cont.

• Goal is to protect Medicare trust fund
• Analyze and identify patterns of payment errors
• Unnecessary admissions, DRG errors, billing
  errors
• Help hospitals to reduce errors through system
  improvement
• QIOs develop tools, education, comparative data
  to share with hospitals to help prevent payment
  errors

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Payment Error Trends

• CMS will continue to sample records from all
  states to monitor the payment error rate
• Data are available for FYs 1998, 2000, 2001,
  2002, and 2003

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CMS HPMP Target Areas
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CMS HPMP Target Areas, cont.
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Numbers of Claims in Error, FY 2003, National Data
includes cases with both admission denial and
DRG change
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Absolute Dollars in Error,FY 2003, National Data
includes cases with both admission denial and
DRG change
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Absolute Dollars in Error, FY 2003, National Data
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Net Dollars in Error, FY 2003National Data
includes cases with both admission denial and
DRG change
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Net Dollars in Error, FY 2003, National Data
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Top 10 DRGs Abs. Dollars in Error (any error)
FY 2003, National Data

• DRG 182
• DRG 296
• DRG 116
• DRG 243
• DRG 127

• DRG 143
• DRG 320
• DRG 468
• DRG 089
• DRG 478

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Top 10 DRGs Abs. Dollars in Error DRG Change FY
2003, National Data

• DRG 468
• DRG 076
• DRG 416
• DRG 089
• DRG 316

• DRG 079
• DRG 148
• DRG 477
• DRG 475
• DRG 296

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Top 10 DRGs Abs. Dollars in Error Adm Den, FY
2003, National Data

• DRG 182
• DRG 243
• DRG 116
• DRG 296
• DRG 143

• DRG 127
• DRG 320
• DRG 012
• DRG 183
• DRG 174

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Trending of Payment Errors, National Data
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Trending Dollars in Error, National Data
32
Trending by Error Type, National Data
33
Payment Error TrendingTexas Data FY 2001 FY
2003
34
Texas Payment Errors Most Recent 4 Quarters
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Texas Payment Error Rate Trending
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Trending of Texas Payment Errors FY 2003 NPE
Sample

• Total of 744 claims sampled
• 54 DRG errors
• 49 ADM errors
• 10 billing errors
• 1 technical denials

• Top DRGs for DRG Errors
• DRG 182 (5 cases)
• Top DRGs for admission denials
• DRG 143 (3 cases)
• DRG 182 (3 cases)
• DRG 243 (3 cases)

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Texas HPMP Activities

• TMF recently completed an HPMP project focusing
  on one-day stays for DRGs 127, 143, 182/183 and
  296/297
• These DRGs comprised 17 of all one-day stays in
  Texas
• 20 hospitals participated (comprised 25 of
  one-day stays in FY 2002)
• Project results indicated reduction in
  unnecessary admissions from 69 to 41

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Texas HPMP Activities

• TMF is analyzing data on short stays (lt3 days)
  for specific DRGs
• TMF will develop specific audits for outlier
  hospitals (by TMF or hospital)
• TMF will include LTCH in data analysis, may
  conduct a HPMP project involving LTCHs
• TMF will continue to distribute PEPPER quarterly
• TMF will continue statewide interventions, such
  as Web-based training, medical staff
  presentations, newsletters, and development of
  tools hospitals can use in their efforts to
  identify and prevent payment errors

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PEPPER

• Program for Evaluating Payment Patterns
  Electronic Report (PEPPER)
• Includes hospital-specific and statewide
  comparative claims data for CMS focus areas
  focus areas are changing in October for
  April-June 2005 discharge data
• Allows hospitals to prioritize auditing and
  monitoring focus by taking into account number of
  discharges and hospital percentile for any focus
  area
• Hospitals can use PEPPER to guide auditing and
  monitoring activities with the goal of
  identifying and preventing payment errors

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HPMP Resources

• www.tmf.org/hpmp
• Coding Guidelines
• Inpatient vs. Outpatient Observation one-pager
• Documentation prompters
• Review worksheets

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Hospital Quality Resources

• Hospital recognition program for achieving
  specified level of improvement
• Surgical care infection prevention project
• Individual quality improvement consultation
• Assessment feedback on HIT adoption plans
• Online resources web-based teleconferences
• Regional quality meetings
• CME/CNE educational programs
• Technical assistance with submitting valid
  publicly reported hospital data

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Questions?
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TMF HPMP Staff

• Robin Fletcher, RN, MPH, Asst. Director of HSA
• Marianne Lundgren, RHIA, CCS, HPMP Specialist
• John Oliver, RN, HPMP Specialist
• Phone [phone]
• E-mail hpmp_at_tmf.org

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DRG Key

• 012 degenerative nervous system disorder
• 014 specific cerebrovascular disorder exc TIA
• 076 other respiratory symptoms or procedures
  w/CC
• 079 respiratory infections inflammations
  agegt17 w/CC
• 089 simple pneumonia pleurisy age gt17 w/CC
• 116 other permanent cardiac pacemaker implant
• 127 heart failure and shock
• 143 chest pain
• 148 major small/large bowel procedures w/CC
• 174 GI hemorrhage w/CC

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DRG Key

• 182/183 esophagitis, gastroenteritis, misc.
  digestive disorder w/ w/o CC
• 243 medical back problems
• 296/297 nutritional/metabolic disorder w/ w/o
  CC
• 316 renal failure
• 320 kidney urinary tract infection age gt 17
  w/CC
• 416 septicemia age gt17
• 468 extensive OR procedure unrelated to
  principal diagnosis
• 475 respiratory system diagnosis with
  ventilator support
• 477 non-extensive OR procedure unrelated to
  principal diagnosis
• 478 other vascular procedures w/CC