Hospital Payment Monitoring Program

The Centers for Medicare & Medicaid Services (CMS) has directed QIOs to perform monitoring of hospital payments. For the Hospital Payment Monitoring Program, Quality Insights will do the following:

• Review all cases referred by the Clinical Data Abstraction Centers (CDACs) as part of a random sample to produce national and statewide error rates for coding and medical necessity to estimate payment error rate for inpatient Perspective Payment System (PPS) services.
  
  
• Review services provided to Medicare beneficiaries to determine if:
  • Services are reasonable and medically necessary
  • Services are provided efficiently in the most appropriate settings
  • Services support the validity and diagnosis of medical information supplied by the provider. In these cases, QIOs will make an initial determination that may result in approval or denial of payment, and/or DRG changes.
    
    
• Monitor hospital admission and coding patterns by conducting statewide hospital profiling and trend monitoring/target identification activities. Quality Insights will analyze state-specific monitoring reports supplied periodically by CMS. Using the reports and case review data, Quality Insights will determine providers' potential for errors and inappropriate utilization.
  
  
• Develop projects to address potentially significant inappropriate utilization and aberrant coding patterns.