Home -- Medicare -- Provider Information -- Hospital Payment Monitoring Program

Hospital Payment Monitoring Program

The purpose of the Hospital Payment Monitoring Program (HPMP) is to measure, monitor, and reduce the incidence of improper fee-for-service inpatient payments, including errors in: DRG coding; provision of medically necessary services; and appropriateness of setting, billing, and prepayment denials. Reducing such errors will, in turn, protect the Medicare Trust Fund. The long-term goal of HPMP is to help inpatient prospective payment system hospitals monitor payment patterns by analyzing data, conducting focused audits, and implementing system changes to prevent payment errors.

PEPPER: Program for Evaluating Payment Patterns Electronic Report

PEPPER is an electronic data report containing hospital-specific Medicare claims data statistics for target areas that have been identified by the Centers for Medicare & Medicaid Services (CMS) as at high risk for payment errors. These target areas include one-day stays, hospital readmissions, and several DRGs that have historically been associated with payment errors.

New HPMP National Web page Now Available!

There is a new Internet resource for hospitals looking to prevent Medicare payment errors and reduce their audit risk. HPMPResources.org provides compliance officers, utilization and health information management professionals, and other staff with one-stop shopping for tools and information related to payment error prevention.

All of the materials on HPMPResources.org are available to hospitals free of charge as part of the Hospital Payment Monitoring Program (HPMP).

HPMP Watch

HPMP Watch indicates the potential for error exists. Individual hospitals may need to monitor the topic of the Watch to ensure that it is not, or does not become, a significant area of concern. It is expected the extent of monitoring will be influenced by factors such as staffing and potential financial impact to the hospital.

Conditions of Participation for Hospitals (CoPs)
There is a concern that hospitals may not be meeting the Conditions of Participation for Hospitals (CoPs)
- Medical record review has identified potential deficiencies in hospital discharge planning. Concerns include failure to ensure availability of post-hospital services, not making appropriate arrangements for post-hospital care before discharge, and not arranging for the initial implementation of the patient's discharge plan. Developed by the Centers for Medicare & Medicaid Services (CMS), Conditions of Participation (CoPs) are standards used to improve quality and protect the health and safety of beneficiaries. CoPs must be met for health care organizations to participate in the Medicare and Medicaid programs.
Local Medical Review Policy for Acute Care (LMRP) L1281
The determination of an inpatient or outpatient status for any given patient is specifically reserved to the admitting physician, although that physician has Medicare guidelines he is expected to follow. The decision must be based on the physician's expectation of the care that the patient will require. The general rule is that the physician should order an inpatient admission for patients who are expected to need hospital care for 24 hours or longer and treat other patients on an outpatient basis. An inpatient admission is not covered when the care can be provided in a less intensive setting without significantly and indirectly threatening the patient's safety or health. Although in many institutions there is no difference between the actual medical services provided in inpatient and observation settings, in such cases the designation still serves to assign patients to an appropriate billing category. The correct physician application of Medicare patient status guidelines is therefore always critically important.

HPMP Warnings

HPMP Warning indicates an actual concern has been cited. Should a Warning be issued, you will be advised on what to look for within your hospital, with suggestions provided regarding actions to take if you identify the topic as an actual area of concern.

HPMP Storm Chasers

As with the constant challenge of changing weather, Medicare is also challenged to protect the Medicare Trust Fund. HPMP Storm Chasers indicates impending changes which could affect compliance and potential financial impact to the hospital.

HPMP Special Studies

Indiana Acute Care Admissions of Beneficiaries Under the Medicare Hospice Benefit

Hospitals and QIO Collaborate to Reduce Unnecessary Admissions

Additional HPMP information may be obtained by calling Health Care Excel's Medicare QIO Help Desk at (800) 300-8190. Indiana hospitals also may obtain HPMP information by e-mail. Indiana: inhpmp@hce.org

Educational Tools

General

Preventive Services Tools

Kentucky Improving Medical Record Documentation

Additional HPMP information may be obtained by calling Health Care Excel's Medicare QIO Help Desk at (800) 300-8190. Kentucky hospitals also may obtain HPMP information by e-mail.

Kentucky: kyhpmp@hce.org

Medicare Outpatient Observation or Inpatient Admission? That is the Question! Recorded May 3, 2007 Webinar Continuing Education (CE) Self-Study

Image of stop sign

Individuals interested in receiving CEs for this self-study should read the requirements in the invitation and instructions linked below. All documents listed below are required to receive credits. Each document is linked to the next required document to allow for a smooth transition. Questions may be directed to the Medicare Provider Help Desk at 1-800-300-8190 or by e-mail inhpmp@hce.org.

Disclaimer:
The educational presentation was taped during the May 3, 2007 live webinar. HCE is aware there are technical difficulties impacting the quality of the recorded presentation. However, we wanted to offer this education for participants that were unable to participate in the original webinar or for those who are interested in hearing the information again.

Invitation and instructions to participate
Pre-knowledge assessment
(Print the completed document for scoring and your records.)
Presentation handouts
Case study handouts
Recorded Webinar Presentation (May 3, 2007)
(If prompted to Save or Open select "Open")
Frequently asked questions
Post-knowledge assessment
(Print the completed document for scoring and your records.)
Knowledge assessment answer key
(Please score your pre- and post-knowledge assessment. Record your scores so you can place them on the verification form at the end of this process.)
Evaluation
(You must complete the pre- and post-knowledge assessment before proceeding to the evaluation. Print the completed evaluation for your records. You will be taken to the verification form to complete electronically. You must enter the password provided at the end of the evaluation to open the verification form. Record it for your records.)
Verification form
(Please complete the evaluation before opening this document. A password is required and is available on the evaluation. Record your pre- and post-knowledge assessment scores on this document. Save this document to your desktop and return to HCE by e-mail or print this document to return by fax or mail.)