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Data Analysis Support and Tracking

Consistent with Sections 1833(e), 1842(a)(2)(B), and 1862(a)(1) of the Social Security Act, the Centers for Medicare & Medicaid Services (CMS) is required to protect the Medicare Trust Funds against inappropriate payments that pose the greatest risk, and take the proper corrective actions.

The Division of Data Analysis activities include the following:
 

PEPPER: The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a comparative data report that provides hospital-specific Medicare data statistics for discharges vulnerable to improper payments. PEPPER can support a hospital or facility's compliance efforts by identifying where it is an outlier for these risk areas. This data can help identify both potential overpayments as well as potential underpayments. PEPPER was created by TMF Health Quality Institute to prioritize hospital-specific findings and provide guidance on areas in which a hospital may want to focus auditing and monitoring efforts. PEPPER identifies areas of potential over-coding and under-coding as well as areas that may be questionable in terms of medical necessity of the admission. Short-term (ST) and Long-term (LT) Acute Care Hospital PEPPERs were the initial reports generated and included this calendar year 2011, Critical Access Hospital (CAH), Inpatient Psychiatric Facility (IPF) and Inpatient Rehabilitation Facility are available. For additional information and training, you can access the Pepper Resources website at http://www.pepperresources.org/

FATHOM: First-Look Analysis Tool for Hospital Outlier Monitoring is a Microsoft Access application that allows CMS to provide each State with hospital-specific Medicare claims data statistics, which identify areas having high payment errors. These target area statistics serve as relative indicators of payment errors. FATHOM reports include: short-term acute care inpatient prospective payment system (IPPS) hospitals (ST FATHOM), long-term acute-care IPPS hospitals (LT FATHOM), CAHs, IRFs and IPF. FATHOMs contain administrative data extracted from the Standard Data Processing System data warehouse for three previous fiscal years (FYs) and the current FY to date (cumulative).

CBRs: A Comparative Billing Report (CBR) provides comparative billing data to an individual health care provider. CBR's contain actual data-driven tables and graphs with an explanation of findings that compare provider's billing and payment patterns to those of their peers on both a national and state level. Graphic presentations contained in these reports help to communicate a provider's billing pattern more clearly. CBR study topic(s) are selected because they are prone to improper payments. For additional information and examples of CBRs, you can access the eGlobalTech website at http://www.cbrinfo.net/

MEDICAL REVIEW SPECIALTY STUDY: To continue to prevent and reduce improper payments, the Division of Data Analysis in the Provider Compliance Group has contracted with StrategicHealthSolutions, LLC to conduct Medical Review Studies of Part A and B claims. These studies occur on a quarterly basis and vary in topic. The first three topics are Inpatient Psychiatric Facility Interrupted Stays, Epidural Injections, and Place-of-Service coding. For more details and contact information you can access the StrategicHealth website at http://www.strategichs.com/