Oversight and Evaluation of the Fiscal Year 2003 Hospital Payment Monitoring Program

EXECUTIVE SUMMARY:

The objectives of this audit were to determine whether the Clinical Data Abstraction Centers (CDACs) followed established Hospital Payment Monitoring Program (HPMP) error rate review policies and procedures, and the HPMP internal quality control process ensured the reliability of the CDAC claims review process.  Our review of 90 inpatient acute care hospital claims found that the CDACs generally followed established HPMP error rate review policies and procedures.  In addition, our review of 45 claims subject to the HPMP internal quality control process showed that controls were generally operating effectively.  However, we noted 2 procedural problems.  For 2 of the 90 sampled claims, one CDAC did not send followup letters requesting medical records.  For 1 of the 45 claims subject to quality control reviews, a quality control procedure was not followed.