Reimbursement Denials Expanded for Medical Errors

As we discussed earlier this year, Medicare has created an ever expanding list of hospital-acquired conditions for which it no longer provides reimbursement. This list includes conditions such as 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 and mediastinitis following coronary bypass surgery.

Further, Medicare has just expanded this list to include the following (which marks a retreat from its initial, overly ambitious proposal):

  • Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity.
  • Certain manifestations of poor control of blood sugar levels.
  • Each e-prescriber may only use approved e-prescribing technology and systems.
  • Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures.

As is often the case, as Medicare goes, so go the commercial payers. As the Chicago Tribune reported yesterday, “if a hospital commits a serious error—such as leaving a sponge in a patient’s chest after open-heart surgery or causing a prolonged illness by mixing up a patient’s medication—Blue Cross and Blue Shield of Illinois says it will no longer pay the claim.” While Blue Cross and Blue Shield of Illinois has not released a detailed list of the never events, it is likely a shorter and less controversial list than Medicare’s list and is believed to only include indisputable ‘never events’ such as leaving a sponge in a patient during surgery.

While Blue Cross and Blue Shield of Illinois is the largest commercial payer to follow Medicare, it certainly will not be last. In fact, it is estimated that payers in more than two dozen states are actively considering similar proposals.

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