Newly adopted Medicare regulations make it clear that Medicare intends to stop reimbursing hospitals for expenses associated with “hospital-acquired conditions”.
Pursuant to the Deficit Reduction Act of 2005 (Pub. L. 109-171), the Secretary identified certain high cost and/or volume preventable conditions that result from inadequate hospital care and are identifiable by unique ICD-9-CM codes. In accordance with the Congressional mandate, CMS will no longer provide reimbursement for such specified hospital-acquired conditions. See 42 C.F.R. 411, et seq..
While many conditions were considered, the list was eventually narrowed down to the following conditions for which Medicare will not provide any reimbursement:
- Pressure ulcers
- Hospital falls
- Certain catheter-associated infections
- Air embolism as a result of surgery
- Leaving an object in during surgery
- Providing incompatible blood or blood products
- Mediastinitis following coronary bypass surgery
It should be noted that existing Medicare regulations prohibit the balance billing of patients. Therefore, if Medicare denies payment for these hospital-acquired conditions, a hospital cannot attempt to pass these costs onto its patients.
Implications for Providers
By some estimates, numerous hospitals will experience millions of dollars in annual reimbursement denials as a result of the new Medicare regulations. However, these new reimbursement rules will not have a direct or immediate impact on physicians. Nevertheless, they do indicate a new direction for Medicare and it is likely that Medicare will eventually apply similar rules to health care providers.
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