Since October 2008, the Centers for Medicare and Medicaid Services (“CMS”) have not paid hospitals for certain hospital-acquired conditions. That is, CMS will not pay for certain conditions that were not present in the patient upon admission. The conditions are, as designated by CMS, conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. These conditions are more commonly known as “never events.”
On June 6, 2011, CMS issued final regulations entitled, “National Policy to Prohibit Medicaid Payment for Provider Preventable Conditions.” These regulations establish the framework for states to establish Medicaid nonpayment policies for other provider preventable conditions. Under the new regulations, an other provider preventable conditionis a condition that occurs in any healthcare setting, including nursing facilities that:
- Is identified in the state plan;
- Has been found by the state, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidence-based guidelines;
- Has a negative consequence for the beneficiary; and
- Is auditable.
Further, the OIG 2012 work plan will investigate the quality of care and safety of beneficiaries transferred from acute care hospitals to post-acute care facilities. The OIG plans to analyze the transfer process and identify rates of adverse events and preventable hospital readmissions from skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals.
On Thursday, April 19, 2012, the Department of Health and Human Services (“HHS”) published a revised draft of its national action plandesigned to prevent never events. Phase 3 of the action plan involves long-term care facilities. HHS states that the population in these facilities is requiring more complex medical care as a result of increased transitions between healthcare settings. These trends can create an increased risk for infections acquired in the health care setting (“healthcare-acquired conditions), which can worsen health status and increase healthcare costs. HHS will release a draft strategy on preventing never events in long-term care for public comment in May 2012.
