Some Adverse Events Lose Coverage

Officials at the Centers for Medicare and Medicaid Services (CMS) have asked states to coordinate their Medicaid policies with Medicare's hospital-acquired-condition payment policy so states do not bear the burden of paying for adverse events.

The issue stems from the announcement by CMS that beginning October 1 Medicare will no longer reimburse hospitals for treatment of 10 conditions, including three newly added conditions, if they are not reported at admission, that is, if they develop in the hospital. The new policy is part of a growing trend among public and private insurers to not pay hospitals for treatment stemming from serious medical errors or a deadly infection that occurs there. The new preventable conditions on the Medicare “do not pay” list are surgical-site infections following elective surgical procedures, some conditions arising from poor control of blood sugar, and deep-vein thrombosis that develops after knee- or hip-replacement surgery.

A July 31 letter to state Medicaid directors from Herb Kuhn, acting director of the Center for Medicaid and State Operations, noted that many Medicare beneficiaries are dual-eligible beneficiaries, that is, who qualify for both Medicare and Medicaid. Kuhn suggested states not pay for “never event-related” incidents by altering their Medicaid plans—which are dually funded by state and federal governments—to deny payment for serious adverse events that Medicare no longer pays for.

Nearly 20 states already have, or are considering, methods to eliminate payment for some “never events,” according to CMS. Other states have attempted to use their “medical necessity” process to refuse payment for some never events.

The AMA has opposed CMS's decision to deny payments over concerns that the denial ultimately would limit patient access to care because some of the conditions are not entirely preventable.

The CMS letter is posted at<www.cms.hhs.gov/SMDL/downloads/SMD073108.pdf>.▪