Surgical devices left inside a patient. Dispensing the wrong medication or the wrong dosage. Giving a patient the wrong blood type in a transfusion. Serious pressure ulcers incurred while hospitalized. Infections from catheterization in the ICU.
These are among the ‘never-ever’ events – incidents that should never, ever happen during an inpatient stay. CMS recently decided to stop paying hospitals for care required due to certain“preventable complications” — “conditions that result from medical errors or improper care and that can reasonably be expected to be averted” (NEJM, 10/18/07). The list includes air embolisms, certain infections, patient falls, pressure ulcers and the like.
HealthPartners in Minnesota was one of the first payers to identify the problem and take action, way back in 2002. Now, other commercial health insurers, notably Wellpoint and Aetna, are planning to move beyond CMS’ list and eventually refuse payment for 28 events. These events, identified by the National Quality Forum are also under review by the Blue Cross/Blue Shield Association, United Healthcare, and CIGNA who may decide to stop paying for them.
And the Leapfrog Group’s membership, which includes many of the country’s largest employers, is also asking providers to not bill for these events.
It is not just the payers; hospitals themselves are starting to see the light. Hospital associations in Massachusetts and Minnesota have agreed to not charge payers or patients for these events, which include “wrong-site and wrong-patient surgery, patient death or disability due to wrong use of blood or blood products and medication errors, and follow-up care needed to bring the patient back from such errors.”
The largest payer in the nation, CMS, has decided that paying for certain medical errors is bad policy. So has two of the largest health plans, along with one of the best-run health plans in the country. Our biggest companies have joined the “no pay for mistakes” movement. Hospitals themselves have decided it is inappropriate to charge for their screw-ups.
So why are workers comp payers reimbursing hospitals for ‘never-evers’? I don’t have any empirical evidence that WC payers are not paying for these events. In fact, given the lax payment policies of most payers, I’d be very surprised if more than a very few (if any) payers have the ability to deny payment, much less a policy to do so.
What does this mean for you?
There is clear precedent for non-payment for medical errors. Moreover, workers comp payers may find themselves in the rather awkward position of trying to justify their payments for conditions that their clients have publicly stated are not reimbursable.
Feb
5
Joe – I am reviewing your last few weeks of postings and was surprised that there were no comments to this post! When CMS announced with great fanfare last summer the plan to not pay for bad medical care, I expected Work Comp payers and medical bill reviewers to be knowledgeable and beginning to introduce this into the medical bill review process. I was disappointed that no-one was aware of the CMS ruling nor had any plans to adopt. This merely lends support to your posting a week later on the future of Work Comp payers! Work Comp payers and players too often operate so far out in left field that their future will be destroyed solely because they do not understand the business in which they live – medical care. And the standard response … “But, this is Work Comp and it is different!” And so it is.