CMS reimbursement rules for never events

Discuss how the CMS reimbursement rules for never events required a shift in the patient
care delivery model in inpatient facilities.

CMS reimbursement rules for never events

In ostensible efforts aimed at improving patient care quality, protecting patient safety, as
well as containing costs simultaneously, the CMS (Center for Medicare and Medicaid Services)
together with patient advocacy groups and third-party payers decided to deny reimbursements to
healthcare institutions for particular conditions acquired following the patient’s hospital
admission. Ominously, these conditions are called ‘never events’. The patient advocacy
organizations and CMS believe that these events are preventable and should never take place
during the period the patient stays in the hospital (McHugh et al., 2011).
Another facet of the ‘never events’ introduction as far as patient care is concerned is that
it is extremely important for physicians to be open to families and patients on adverse events.
This will bring about an effect on the manner in which professional liability cases get litigated. It
is not yet clear how the litigation will be influenced (Mattie & Webster, 2008). However, it is
already clear that despite the intent of creating the ‘never events’, plaintiffs’ bar potentially has
been given a novel weapon.
In the inpatient healthcare setting, reimbursement in this case affects patients suffering
from pulmonary emboli and deep vein thromboses associated with hip and knee replacements,
and particular poor glycemic control manifestations. Some of the new ‘never events’ include
wrong body part surgery, operating on the wrong patient, and doing a wrong surgery on a patient
(McHugh et al., 2011).

Medicare does not commit to paying for higher MD-DRGs that arise from certain
conditions in case they begin after admission. Theoretically, this implies that for dual eligibles,
the institution can attempt billing Medicaid as the secondary payer.



Mattie, A. S., & Webster, B. L. (2008). Centers for Medicare and Medicaid Services’ “never
events”: an analysis and recommendations to hospitals. The Health Care Manager, 27,
McHugh, M., Van, D. K., Osei-Anto, A., & Haque, A. (2011). Medicare’s Payment Policy for
Hospital-Acquired Conditions: Perspectives of Administrators From Safety Net
Hospitals. Medical Care Research and Review, 68, 6, 667-682.

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