The objective of the Hospital Payment Monitoring Program (HPMP) is to measure, monitor, and reduce the incidence of improper Fee-for-Service inpatient payments among New Jersey's acute care hospitals, including errors in Diagnosis-Related Group (DRG) assignment and ICD-9-CM coding; provision of medically unnecessary services; and inappropriateness of setting, billing, and prepayment denial.
The Centers for Medicare & Medicaid Services (CMS) requires that HQSI be responsible for the following in New Jersey acute care hospitals:
- Review of services provided to Medicare beneficiaries under the Medicare program to determine whether such services are reasonable and medically necessary, are provided efficiently and in the most appropriate setting, support the coding validity of medical information supplied by provider, are correctly billed, and are properly denied. Subsequently, HQSI makes initial determinations that may result in approval or denial of payment and/or DRG changes. Cases reviewed by HQSI include those:
- Referred by the Clinical Data Abstraction Center (CDAC) as part of a random sample to estimate national and state payment error rates for short-term acute care inpatient Fee-for-Service reimbursements. The short-term inpatient acute care payment error rate is monitored and reported nationally and for each stat/jurisdiction
- Referred by CMS as part of a random sample to estimate a national payment error rate for long-term actue care inpatient Fee-for-Service payments
- Referred by CMS as part of a random sample to estimate national and fiscal intermediary-specific payment error rates for denied claims
- Monitoring of acute care facility admission, coding, and billing patterns in New Jersey by conducting profiling and trending for short-term acute care inpatient services. To supplement information HQSI has available, CMS supplies HQSI with periodic provider-specific monitoring reports for acute care facilities in New Jersey. HQSI analyzes these reports and, coupled with the information HQSI has developed through profiling of case review data and other appropriate sources, determines potential target areas of inappropriate utilization, coding errors, and billing errors
- Implementation of the Short Hospital Stays Project with 15 acute care hospitals, which is designed to reduce the number of medically unnecessary admissions in short hospital stays (one to three days) for specific DRGs.