FROM: Theodore O. Will, Chief Executive Officer
DATE: Feb 23, 2000
SUBJECT: Payment Error Prevention Program (PEPP): IPRO Intervention Plan
IPRO CONTACTS:
Andrea Goldstein, Vice President, Health Care Assessment, Extension 364 and Paula Monetti, Sr. Director, Program Integrity, Extension 261
Enclosed please find a copy of IPRO's Intervention Plan which describes our educational and feedback initiatives for Year One of the Payment Error Prevention Program (PEPP). Please share this memorandum with all interested hospital personnel.
IPRO recognizes that the success of our plan coincides with the hospitals' ability to effect change and improve coding and billing practices. With this end in mind, we seek your input in regard to other intervention strategies you may have utilized which foster improvement. Plans for an "Interventions" conference call are currently underway. Please call Andrea Goldstein if you would be interested in presenting successful approaches which have been utilized in your hospital.
Should you have any questions or comments in regard to PEPP or the enclosed "Intervention Plan", please feel free to contact Andrea Goldstein or Paula Monetti.
I. Introduction
The Medicare Sixth Scope of Work (SOW) (August 1, 1999 - July 31, 2002) includes a directive by the Health Care Financing Administration (HCFA) that all Peer Review Organizations (PROs) initiate a Payment Error Prevention Program (PEPP).
The goal of PEPP is to analyze and reduce inpatient Medicare billing errors through a variety of methods including assessments of correct coding and determinations of medical necessity. IPRO has planned and initiated a program that focuses on identifying these issues as well as resolving the sources(s) of the errors through collaboration with hospitals in New York State. In general, all PEPP projects will follow the "baseline-intervene-remeasure" process. Additionally, IPRO's PEPP projects will follow clearly defined stages and time-lines to ensure that a) the program functions effectively, b) hospitals receive continuous feedback; and c) interventions are ongoing.
II. PEPP Intervention Plan
The stages that each project will pass through are: a comprehensive literature review, data analysis using data mining analytical methods, advisory group meetings, sampling, tool development and programming, reliability & validity testing, data abstraction, data cleaning and analysis, report generation, intervention and/or implementation of hospital changes, remeasurement, report generation and final project assessment. Our Intervention Plan, which follows, incorporates numerous educational and training initiatives designed to reduce future payment errors leading to a reduction in the statewide error rate.
A. Overview
Implementing successful interventions begins with a thorough analysis of the factors that may lead to payment errors. Identification of significant trends or patterns through data analysis and other more qualitative approaches help define whether an intervention is warranted. A determination as to which specific intervention strategy is most likely to reduce payment errors will be based on IPRO's analysis of the root causes of the specific problem and whether it is statewide, regional or hospital focused. In keeping with the philosophy of PEPP, we anticipate that education and dissemination of information to the hospital community will be the most frequently used tools to effect change.
IPRO will develop collaborative relationships with hospital-designated PEPP Liaisons who will coordinate projects with IPRO and appropriate hospital representatives, e.g., Medical Records Director, Vice President for Medical Affairs, Utilization Review Committee Chair and/or Compliance Officer. IPRO expects these individuals will be valuable resources to the Payment Error Prevention Program and will assist IPRO in developing meaningful and useful hospital data reports, analyzing trends as well as assisting their facility in developing internal educational programs in response to IPRO findings. IPRO is also available to work with the PEPP Liaison in setting up internal controls to promote adherence to applicable coding and billing guidelines and in tailoring programs to assure ongoing compliance.
B. Approach
IPRO will utilize a team approach in developing and implementing interventions, taking advantage of well-established, existing IPRO Committees that have supported our provider education programs and provider/practitioner collaborative efforts in the past. Consultation with the membership of these Committees generates valuable ideas and insights from the medical and provider communities that assist IPRO in designing appropriate and effective thresholds and interventions:
This Committee includes representatives from state and local hospital associations, individual providers, health information management (HIM) organizations, risk management and financial management groups. This Committee facilitates IPRO's communication with the hospitals, home health agencies and nursing facilities regarding the PRO program. A PRC sub-committee on hospital compliance has been created to promote the use of the OIG voluntary compliance plan throughout the State. In addition, the members offer valuable suggestions in regard to potential PEPP project areas.
This Committee includes representatives from specialty societies and hospital medical directors. The members serve as a valuable resource to IPRO and the PEPP management team in the development of clinical indicators, guidelines and/or criteria which are used for review activities. In addition, under PEPP they will continue to provide specialty society access, identification of specialists for work groups and may assist in the development and design of statewide clinical intervention activities, as appropriate.
C. Focus Areas - Year One
IPRO's PEPP activities for Year One include both coding/DRG validation projects as well as potential patterns of mis-utilization. A brief overview of these two areas of interest follows:
As a result of our comprehensive literature review, trends were identified which served as markers for further investigation. These trends identified national patterns of upcoding for select DRG pairs. Data analysis, using the 1997-1998 New York State Medicare database, was conducted to assess state and hospital specific coding patterns and/or DRG trends.
The Office of the Inspector General (OIG), Office of Audit Services Opinion of HCFA's 1997 Financial Statement identified billing errors that were associated with unnecessary or inappropriate inpatient admissions for services which did not require hospitalization or which were more appropriately treated in alternate settings. IPRO's Year One Data Analysis Plan includes identification of potential inappropriate/unnecessary inpatient admission patterns within NYS. In Year One, IPRO has selected PEPP projects which focus on unnecessary/inappropriate admission in the areas of readmissions within thirty-days and one day stays.
D. Intervention Strategies
As previously noted, IPRO will utilize the "baseline-intervene-remeasure" approach to carry out PEPP. In keeping with the philosophy of quality improvement, IPRO believes the most successful way to effect a reduction in the payment error rate is through the sharing of meaningful data with the hospitals and medical community. This is further enhanced through the promotion of open communication between the hospitals and the PEPP Management Team as well as by provision of educational opportunities. Thus, IPRO will use a variety of intervention methodologies to reduce the NYS inpatient PPS hospital payment error rates. Interventions that IPRO has planned include, but are not limited to, the following:
Statewide Hospital-Specific ReportsStatewide and/or regional mailings will be sent to hospitals when pattern analysis, case abstraction and/or chart review identify broad opportunities for reducing NYS payment errors through improvements in coding and billing or by reducing inappropriate/
unnecessary admissions. Individualized comparative information will be presented reflecting the hospital's data versus statewide, regional or national data.
The statewide mailings may be followed by hospital-specific communication for projects that reveal unusual patterns at individual hospitals. In some situations, only focused hospital mailings will be sent if the problem identified is unique to certain hospitals, i.e., significant trends or patterns requiring remediation are identified through data abstraction and case review.
Regional conferences and/or teleconferences will be arranged so that all hospitals may benefit from community-wide discussions of improvement methodologies. Through this forum, IPRO will present additional PEPP project information and provide training for hospital coders. CEU credits will be available for participating hospital coders who successfully complete the course work. CME programs for physicians may also be developed, as appropriate, for CME credit.
Over the course of the three year Medicare PEPP program, IPRO intends to meet with New York State hospitals and appropriate representatives to review the PEPP program and discuss hospital-specific plans including internal education programs.
IPRO is preparing the "Resource Guide for Planning and Implementing PEPP Activities" for release early in 2000. The materials and tools included in this Guide will assist hospitals in developing and implementing their own internal programs for payment error prevention. The Resource Guide will include background on the PEPP program, the role of the hospital, physicians and coders, DRG coding abstraction tools with instructions and other reference materials. The Resource Guide will be updated by IPRO based upon new PEPP initiatives and will include materials and information related to the projects.
HCFA's Payment Error Prevention Support PRO (PEPSPRO), The Texas Medical Foundation (TMF) has introduced a PEPP General Introduction Video. Under separate cover, each hospital has been sent a copy to use in introducing PEPP to their Medical Records, Utilization Management and Medical Affairs staff.
IPRO is developing a PEPP Web Page, as part of its web site, www.ipro.org, which will provide current information on IPRO's Payment Error Prevention Program. In the future, the Website may be used as a means to communicate between the PEPP Management Team and with hospitals. Hospitals are encouraged to share their ideas for PEPP projects with IPRO via the Website at www.ipro.org.
III. Summary
IPRO's PEPP Intervention Plan will be implemented during Year One and will continue to evolve through Years Two and Three as new approaches are identified. Moreover, IPRO believes that through continuous collaboration with the hospitals and medical community across the State, intervention strategies will emerge that will promote success, i.e., reduction in the NYS inpatient error rate.
In summary, the goal of reducing hospital inpatient errors through implementation of educational intervention strategies such as correct coding initiatives and assuring the appropriateness/medical necessity of hospital admissions is attainable. The "baseline-intervene-remeasure" process will evaluate the effectiveness of the program and provide valuable feedback to the New York hospital community, IPRO and other PROs as well as HCFA as to "what works."