Iowa Foundation for Medical Care
Payment Error Prevention Program (PEPP)

The Payment Error Prevention Program (PEPP) is a nationwide quality improvement effort that focuses on admission necessity and the accuracy of Diagnosis Related Group assignment. The goal of PEPP is to implement system changes that reduce payment error in the acute care hospital setting with an educational focus.

The Iowa Foundation for Medical Care (IFMC) uses data collection to monitor hospital progress in reducing payment errors related to unnecessary admissions for the discharge diagnoses of pneumonia, chronic obstructive pulmonary disease (COPD), heart failure, urinary tract infection and back pain. Nurse coordinators review each medical record using IFMC Acute Assessment and Services nurse screening criteria. Hospitalizations failing to meet the criteria are categorized as potential admission errors.

Aggregate data collection analysis revealed that the diagnoses of COPD and back pain failed the nurse screening admission criteria greater than 80 percent of the time and 66 percent failed physician review. Therefore, IFMC implemented a special project that focused on reducing unnecessary admissions for these diagnoses.

To provide information gained from the special project a "Special Project Findings"; document has been developed which includes: 1) case scenarios of COPD and back pain admissions determined to be medically unnecessary by a physician reviewer and 2) COPD and back pain admissions where documentation in the medical record supported an acute hospitalization.

Complete documentation at the time of admissions that supports the decision to admit the patient to the acute inpatient setting is essential. Our ongoing goal is to collaborate with health care providers by providing education and feedback that will assist in reducing potential payment errors caused by medically unnecessary admissions.

The "Special Project Findings"; document is available from IFMC upon request. To request a copy please contact Margaret Jones at 1-800-383-2856, extension 8042.