Hospital Payment Monitoring Program (HPMP)

Current Medicare work for GMCF includes the Hospital Payment Monitoring Program (HPMP), which replaces the Payment Error Prevention Program (PEPP). The purpose of the Centers for Medicare & Medicaid Services (CMS) directed program is to reduce the amount of Medicare funds improperly paid to acute care hospitals.

GMCF responsibilities in the HPMP include the assessment of:

Medical necessity of care provided
Appropriate level of care
Appropriate diagnostic/procedural codes
Adequacy of documentation
Circumvention of payment guidelines

Georgia's payment error rate will be determined by CMS based on review results. Randomly selected cases are screened and referred by the Clinical Data Abstraction Center (CDAC) and processed through the standard GMCF review process, including physician reviewers.

In addition, GMCF will analyze Medicare discharges to determine potential problem patterns in admission and/or coding. If potential problem patterns are identified, and CMS approves, hospitals will be engaged in specifically designed projects.

Effective August 1, 2008 with the beginning of the 9th Statement of Work (9SOW), Quality Improvement Organizations (QIOs) will no longer be responsible for implementing the Hospital Payment Monitoring Program (HPMP).

The purpose of HPMP is to measure, monitor, and reduce the incidence of improper fee-for-service inpatient acute care Medicare payments. QIOs will no longer be responsible for these functions and funding for support and educational assistance related to HPMP will cease. Responsibilities are being transferred to other entities. Georgia acute care hospitals may wish to contact the following organizations for questions previously directed to GMCF related to compliance or payment error reduction activities:

Compliance-related questions: Health Care Compliance Association
Billing questions: Fiscal Intermediary or Medicare Administrative Contractor

Since 2006 Georgia Medical Care Foundation (GMCF) has distributed quarterly hospital-specific comparative data report, the Program for Evaluating Payment Patterns Electronic Report, or PEPPER. Although not required to do so, GMCF will continue to distribute PEPPERs through the January 2009 data release. It has not been determined at this time whether PEPPERs will be generated after January 2009. The tools and resources posted at http://www.hpmpresources.org will be available through January 2009.

For error rate calculation, the final sample under HPMP was selected in February 2008; October 2007 discharges were sampled. Inpatient records for calculating the national fee-for-service Medicare error rate will be sampled under the Comprehensive Error Rate Testing (CERT) program beginning in April 2008. View more information on the CERT program.

GMCF will continue to perform other statutory and regulatory mandated review activity and quality improvement as described in the 9SOW.

Effective October 1, 2007, Medicare Severity DRGs (MS-DRGs) replaced CMS DRGs. The target areas included in PEPPER have been revised to reflect the new MS-DRGs, and where possible have been constructed to be analogous with the CMS DRG target areas so that data can be trended over time. Revisions can be found in the PEPPER User’s Guide distributed with each PEPPER version. Revisions include:

short-term acute care hospital readmission target area has been revised and a new renal failure target area added
long-term acute care hospital short stays target areas have been revised

Tools

One-Day Stay Special Project (pdf)