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Division of Compliance, Projects and Demonstrations

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 Compliance, Projects and Demonstrations activities include the following:

PEPPER: The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a comparative data report that summarizes one provider’s Medicare claims data statistics for services vulnerable to improper Medicare payments. PEPPER can support a hospital or facility's compliance efforts by identifying where its billing patterns are different from the majority of other providers in the nation. This data can help identify both potential overpayments as well as potential underpayments. PEPPER was created by TMF Health Quality Institute to prioritize findings and provide guidance on areas in which a provider may want to focus auditing and monitoring efforts with the goal of preventing improper Medicare payments. PEPPER identifies areas of potential over-coding and under-coding as well as areas that may be questionable in terms of admission necessity. PEPPERs are available for Short-term (ST) and Long-term (LT) Acute Care Hospitals, Critical Access Hospitals (CAHs), Inpatient Psychiatric Facilities (IPFs), Inpatient Rehabilitation Facilities (IRFs), Hospices, Partial Hospitalization Programs (PHPs), Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs). PEPPERs are not publicly available; they are only distributed to each individual provider. For additional information and resources, please visit the PEPPER Resources website at http://www.pepperresources.org/.

FATHOM: The First-Look Analysis Tool for Hospital Outlier Monitoring (FATHOM) is a Microsoft Access application that allows CMS to generate reports on providers summarizing Medicare claims data for areas identified as vulnerable to improper Medicare payments. FATHOM reports can be generated for Short-term (ST) and Long-term (LT) Acute Care Hospitals, Critical Access Hospitals (CAHs), Inpatient Psychiatric Facilities (IPFs), Inpatient Rehabilitation Facilities (IRFs), Hospices, Partial Hospitalization Programs (PHPs) Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs). FATHOMs are not publicly available; they are only distributed to CMS, Medicare Administrative Contractors and Recovery Auditors. FATHOM is produced and distributed by TMF Health Quality Institute.

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 Compliance, Projects and Demonstrations 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 StrategicHealthSolutions, LLC website at http://www.strategichs.com/.