The Center for Medicare and Medicaid (CMS) reimbursement rules establish payment rules related to health conditions happening during the hospital stay that are not present upon admission.
The Center for Medicare and Medicaid (CMS) reimbursement rules establish payment rules related to health conditions happening during the hospital stay that are not present upon admission. These conditions are generally known under the terms “never events” (Stone, W., P.; Glied, A., S.; McNair, D.,P.; Matthes, N.; Cohen, B., Landers, F.; T.; & Larson, L., E.
This policy addresses preventable health conditions such as infections, inpatient morbidity and mortality. Regulations resulting from CMS policy reject payment for the previously mentioned conditions.
The particularity of this policy is that it brings a shift in the patient care delivery model in inpatient facilities. Notably, physicians, healthcare management, and other inpatients interested parties carry the risk of becoming liable of any person providing inpatient care. With liability risk for inpatient care delivery, physicians are become more careful while they are performing any types of medical interventions on patients. They are compelled to be attentive in monitoring patients’ health conditions.
The innovative and intended goal of this shift is to improve the quality of care received during a hospital stay. Particularly, CMS policy is targeted at averting hospital-acquired conditions
Never Events as termed by the Center for Medicare and Medicaid Services (CMS), are complications that are “preventable by following evidence-based guidelines and thus CMS no longer reimburses for medical services rendered to treat them” (O’Rourke & Hershey, 2009). These are injuries or illnesses, 28 in all, that could have been prevented if the hospital had taken proper prevention, some examples are catheter associated infections, air emboli, falls, and pressure ulcers. When these types of injuries occur, the burden is now on the health care provider to prove they occurred in absence of negligence. Health care providers must know and follow the evidence base protocols when it comes to these ‘Never Events’ to prevent them and get reimbursed. Private health insurance companies are also following CMS and notifying hospitals about not paying for hospital mistakes. To counter act these ‘Never Events’ patients may experience more testing before admission to hospitals to prove they did or did not have any infection prior to. Or “infected patient may be discharge too soon to only come back with the infection and then CMS has to pay for the newly admitted patient that arrived with an infection” (Torrey, 2018). So, basically these ‘Never Event’ still mean cost are passed on to the patients. Either by treatment prices going up that are passed on to the patient or by not being ‘cured’ prior to discharge only to come back again and now being billed for that infection. Even though the ‘Never Events’ was design to protect the patient from certain consequences it definitely produced other consequences like cost and sometimes death.
The Centers for Medicare and Medicaid Services (CMS) adopted the non-reimbursement policy for certain hospital acquired conditions or occurrences which have been deemed as never events by explaining that these events are reasonably preventable through evidence based practice (Lembitz & Clarke, 2009). The Centers for Disease Control (CDC) estimated costs of healthcare-associated infections in U.S. hospitals to be between $28 and $45 billion per year with the top three leading causes being pressure ulcers, postop infections and mechanical complication if a device such as graft (Preventing Never, 2011). Such non-reimbursable events are used to motivate hospitals to make changes to better care for patients by implementing standardized protocols (Lembitz & Clarke, 2009). Also, such events deemed reasonably preventable by provided adequate care limit the ability for hospitals to bill Medicare for adverse events and complications (Lembitz & Clarke, 2009). Such events include wrong surgery on patient or wrong site, death or disability due to incompatible blood products, pressure ulcers post admission, fall within the facility and well as hospital acquired infections such as CAUTI, surgical site infection post CABG or bariatric surgery or orthopedic surgery as well as post knee or hip replacement surgery DVT or PE (Lembitz & Clarke, 2009). Hospitals are implementing protocols to encourage staff to assist in preventing never events therefore preventing non-reimbursement events (Lembitz & Clarke, 2009). These include identifying fall risks and labeling the patients appropriately so all staff are aware, double nurse checks on blood administration, time-outs taken in surgery and reducing hospital acquired infections by using evidence based practice guidelines (Lembitz & Clarke, 2009). Another factor that can affect avoiding never events is adding one staff RN to the nurse-to-patient ratio. One additional patient per RN per shift was associated with increased risk of: failure to rescue cases (7% increase), hospital acquired pneumonia (7% increase), pulmonary failure (53% increase), unplanned extubation (45% increase), medical complications (17% increase) (Preventing Never, 2011).