What is the purpose of the HPMP? to measure, monitor, and reduce the incidence of improper fee-for-service inpatient payments, including
- DRG coding errors;
- provision of medically necessary services; and
- appropriateness of setting, billing, and pre-payment denial.
Qualis Health reviews all cases referred by the Clinical Data Abstraction Center (CDAC) as part of a random sample to produce a national and statewide error rate for coding and medical necessity for estimating the payment error rate for Prospective Payment System (PPS) inpatient services. The payment error rate will be monitored and reported for each state.
What does the HPMP entail? Qualis reviews services provided to Medicare beneficiaries under the Medicare program to determine whether such services
- are reasonable and medically necessary,
- are provided efficiently in the most appropriate setting, and
- support the validity and diagnosis of medical information supplied by the provider.
Subsequently, Qualis Health makes initial determinations that may result in approval or denial of payment and/or DRG changes.
How is the HPMP carried out? Qualis Health monitors the hospital admission and coding patterns in Idaho and Washington by conducting hospital profiling and trend monitoring/target identification activities. To supplement other information that Qualis Health has available to it, the Centers for Medicare & Medicaid Services (CMS) supplies Qualis Health with periodic monitoring reports, specific to all hospitals in the state or jurisdiction. Qualis Health analyzes these reports and, coupled with information independently developed through analysis of case review data and other appropriate sources, determines potential target areas of inappropriate utilization, coding errors, and billing errors.
Qualis Health develops project proposals to address identified and potentially significant inappropriate utilization and aberrant coding patterns and submit them to its CMS project officer for approval. Qualis Health reports and disseminates the results of its monitoring and project activities. The development and implementation of any project must be well-documented and supported by the results of Qualis Health’s monitoring activities of hospital admission and coding patterns. Additionally, CMS may direct Qualis Health to conduct specific error prevention projects.
