Mid-Atlantic Health Law TOPICS

Starting October 1, 2008, the Centers for Medicare and Medicaid (CMS) will no longer reimburse hospitals for 11 conditions attributable to avoidable secondary conditions acquired by patients during hospital stays. The CMS rule also prohibits hospitals from billing affected patients for any charges associated with the 11 conditions.

A. Never Events

To encourage hospitals to pay more attention to errors and injuries deemed to be reasonably preventable by generally accepted guidelines, CMS selected 11 severe adverse events or hospital acquired conditions, commonly known as “never events”, for which it will deny reimbursement.

Unless documented as present upon hospital admission, hospitals will not receive payment for any costs associated with these never events:

1. Foreign objects retained after surgery;

2. Air embolisms;

3. Blood incompatibility;

4. Catheter-associated urinary tract infections;

5. Stage III and IV pressure ulcers;

6. Surgical site infection-Mediastinitis after coronary artery bypass grafts;

7. Vascular catheter-associated infections;

8. Falls or trauma resulting in fractures, burns, dislocations or serious injury;

9. Surgical site infections following certain orthopedic procedures and bariatric surgery for obesity;

10. Manifestations of poor blood sugar control, such as diabetic ketoacidosis and hypoglycemic coma; and

11. Deep vein thromboses or pulmonary emboli associated with total knee and hip replacement procedures.

B. Maryland Response

At present, it is unclear how Maryland’s hospitals will be affected by this new development. Maryland operates under a “waiver” from the Medicare system, meaning that hospitals in Maryland are paid for services provided to all patients, including Medicare patients, according to the rates set by Maryland’s Health Services Cost Review Commission (HSCRC), not by Medicare.

Nevertheless, it is likely that the HSCRC will also shortly adopt a non-reimbursement rule for “never events” that may be similar or different than the federal rule. However, whether an HSCRC rule substantively differs from the federal rule or not, it is important to remember that an HSCRC rule would apply to all payors, and not just to Medicare.