NMMRA Articles

Published In: AHQA Matters

NMMRA Develops New Tool to Assist Short-term Acute Care Hospitals in Tracking Actual Payment Error

The Hospital Payment Monitoring Program (HPMP) team at the New Mexico Medical Review Association (NMMRA) recently developed a new electronic reporting tool to assist hospitals in their compliance efforts.

Developed in response to requests from hospitals across the state, the tool seeks to help short-term acute care facilities track the types of errors and dollars related to payment errors occurring in their facilities. The Hospital-specific Actual Payment Error Report (H-SAPER) summarizes the final results of claims submitted by hospitals to Medicare, which were denied payment or adjusted after review by NMMRA.

Review Letters Don't Tell the Whole Story

After the QIO reaches a final determination on review of a hospital claim, a review letter is sent to the hospital's QIO liaison.

However, these letters do not include information on the dollars associated with any errors found or the final reimbursement amount. H-SAPER tool provides hospitals a more comprehensive look at erroneous claims. The tool creates a report summarizing information already contained in the review letter and provides additional information regarding error type, error code and beneficiary identifying information for each claim where an error was found. The report also includes the original payment amount, the payment adjustment or denial (net error amount) and the final payment amount.

Five types of payment errors are included in the report: admission denials, prohibited actions, diagnosis-related group (DRG) changes, billing errors and technical denials. The tool is in a Microsoft Excel spreadsheet format containing hospital-specific error data, an explanation of the error codes, fiscal year trends and original-to-final payment comparisons.

How Can Hospitals Use the H-SAPER?

Unlike the Program for Evaluating Payment Patterns Electronic Report (PEPPER), which identifies potential payment errors for various target categories, H-SAPER gives hospitals information on actual payment errors incurred by their facilities.

Hospitals can sort the information by category of error, reason for the error, and timeframe in which the error occurred, so they can analyze and drill down into their own payment error data to identify gaps in admission, coding, and billing processes.

Hospitals are encouraged to prioritize their monitoring efforts based on error type or total amount of dollars in error. Several occurrences of one error type may indicate an area of concern that should be addressed through process changes or system alignment. Likewise, individual errors that yield high dollar payment adjustment may be reviewed. H-SAPER graphically highlights where hospitals are losing dollars to undercoding or losing the total amount billed due to an admission denial.

H-SAPER debuted in June 2006 in all New Mexico short-term acute care hospitals that had at least one payment error during the previous eight quarters (2004Q1 to through 2005Q4). Reports are distributed quarterly via QualityNet (QNet) Exchange to those facilities that had at least one new error for the new time period. New errors are labeled and appear at the top of the report for easy identification. Hospitals with no new errors receive a congratulatory e-mail.

The distribution process includes an e-mail notification about the report's availability to the compliance officer at each facility.

Since the initial upload, many compliance officers have chosen to become QNet Exchange users in order to gain access to the reports in a more timely manner. An indication of the value of these reports is that every hospital receiving a report downloads it within two weeks of distribution in QNet Exchange. This access has also increased the number of New Mexico hospitals downloading the PEPPER.

The Arkansas Foundation for Medical Care tested it and provided feedback, and the tool was then modified for general distribution to QIOs. NMMRA recently presented H-SAPER to the HPMP QIO community via an HPMP Community of Practice call. The tool, instructions, and templates, are available by contacting NMMRA.

This tool is most appropriate for states with fewer total discharges from which the surveillance sample of 62 charts per month are drawn and reviewed for errors.

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