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: PEPPER is an electronic report that provides provider-specific Medicare data statistics for discharges/services vulnerable to improper payments. PEPPER cannot be used to identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts to help providers identify and prevent payment errors. PEPPERs are sent to facilities such as Short-Term Hospitals, Long-Term Hospitals, Critical Access Hospitals, Hospices, Inpatient Rehabilitation Facilities, Partial Hospitalization Programs, Skilled Nursing Facilities, Inpatient Psychiatric Facilities, and Home Health Agencies. For more information on PEPPER, click here.
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/