The Payment Error Prevention Program (PEPP)

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The Payment Error Prevention Program (PEPP)
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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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