Medicare to Stop Paying for Certain “Never Events”

Beginning tomorrow, Medicare will no longer provide reimbursement for certain newly added “never event.” In particular, Medicare will refuse to provide reimbursement for the following conditions:

  • Surgical site infections following certain elective procedures
  • Legionnaires’ disease
  • Extreme blood sugar derangement
  • Lung collapse (Iatrogenic pneumothorax)
  • Delirium
  • Ventilator-associated pneumonia
  • Formation/movement of a blood clot (Deep vein thrombosis/Pulmonary Embolism)
  • Bloodstream infection (Staphylococcus aureus septicemia )
  • Bacterial infection that causes severe diarrhea and serious intestinal conditions such as colitis (Clostridium difficile associated disease)

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CMS has explained that the underlying rationale for denying reimbursement is “to strengthen the tie between the quality of care provided to Medicare beneficiaries and payment for the services provided when they are in the hospital.” This goal is consistent with the Deficit Reduction Act of 2005 (Pub. L. 109-171), which requires the Secretary of HHS to identify certain high cost and/or high volume preventable conditions that result from inadequate hospital care and are identifiable by unique ICD-9-CM codes.

Finally, if you manage hospital A/R, you should remember that you are prohibited from billing patients for these claims, even though they will be denied by Medicare.

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