Nonpayment For Serious Adverse Events

Description

In 2002, the National Quality forum (NQF) published Serious Reportable Events in Healthcare: A Consensus Report, which outlined a list of adverse events that were "serious, largely preventable and of concern to both the public and health care providers." These events and subsequent revisions to the lists became known as "never events."

“A hospital-acquired condition (HAC) is one of several medical conditions a patient can acquire during a hospital stay that was not present on admission (POA). The Centers for Medicare & Medicaid Services (CMS) have used this designation since October 1, 2008, which may result in adjustments to hospital payments.”

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) does not allow reimbursement for serious adverse events according to the criteria outlined in this policy.

Reimbursement Guidelines

Blue Cross NC applies POA, HAC, and Never Event editing. Reimbursement is not allowed for inpatient or outpatient services related to Hospital-Acquired Conditions and Never Events as defined by CMS.

Billing and Coding

This policy applies to codes listed on the following CMS websites:

Centers for Medicare and Medicaid Services (CMS). Hospital-Acquired Conditions (Present on Admission Indicator). Hospital-Acquired Conditions (Present on Admission Indicator) | CMS

Centers for Medicare and Medicaid Services (CMS). Hospital-Acquired Conditions (Present on Admission Indicator). IPPS For FY 2013- 2023 Final Rule. Hospital-Acquired Conditions | CMS

Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. CMS Chapter 32

Related policy

n/a

References

Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. CMS Chapter 32: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c32.pdf

Centers for Medicare and Medicaid Services (CMS). Hospital-Acquired Conditions (Present on Admission Indicator). Hospital-Acquired Conditions (Present on Admission Indicator) | CMS:https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitalacqcond?redirect=/hospitalacqcond/

Centers for Medicare and Medicaid Services (CMS). Hospital-Acquired Conditions (Present on Admission Indicator). IPPS FY 2013-2023 Final Rule. Hospital-Acquired Conditions | CMS: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions

History

11/1/2023 - New policy developed. Medical Director approved. Notification on 11/1/2023 for effective date 1/1/2024. (ss)

Application

These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.

This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.