CMS Reimbursement Rules for “Never Events

As part of its ongoing efforts to ensure patients receive better care, the Center for Medicaid Services eliminated the long-standing presumption on its payment rules. Ideally, it was presumed that hospitals do everything possible to prevent complications during the treatment procedures for inpatients and that the taxpayer and individuals should solely bear costs when complications occurred (Milstein, 2009). In this context, the CMS announced that the federal payer programs would no longer reimburse for medical services administered for specific treatment complications also referred to as the “never events.” The reasoning behind the decision was that majority of these complications were reasonably preventable if healthcare providers followed evidence-based guidelines. Consequently, the new CMS policy affects not only the payment implications but also the liability risk of the medical personnel providing inpatient care, regardless of the payer involved. In its press release, the Center for Medicaid Services was categorical on the fact that, when patients seek treatment for one medical problem, they do not expect to leave with additional infections or injuries incurred during their stay at the hospital. Conceptually, the CMS projected that its new policy would significantly affect the delivery of care model especially in the inpatient facility.

Ideally, preventable medical errors constitute procedures such as performing surgery on the wrong body part, wrong surgery on a patient, retention of foreign objects, and infections at surgical site among others (Center for Medicare & Medicaid Services, 2009). The “never events” are often seen as a healthcare professional’s negligence, because they can be prevented if physicians, nurses, and medical staff responsible paid more attention when providing care. As Milstein notes, what this means for the Patient Care Delivery model is that, nurses, doctors, and other medical personnel will take extra caution, and the number of medical errors will be considerably reduced. Consequently, nurse leaders will also have to take a strategic approach to prevention to increase effective and efficient care delivery outcomes. More specifically, it is expected that nurses and other medical personnel will adopt optimal assessment such as standardized risk evaluation and use of evidence-based tools to reduce risks and increase patient safety. Healthcare facilities are also more likely to consider cutting-edge technologies to prevent the risk of never events such as pressure ulcers from occurring at the facility.

References

Milstein, A. (2009). Ending Extra Payment for “Never Events” — Stronger Incentives for Patients’ Safety. New England Journal of Medicine, 360(23), 2388-2390.

Center for Medicare & Medicaid Services. (2006). Eliminating serious, preventable, and costly medical errors – never events. Retrieved from: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2006-Fact-sheets-items/2006-05-18.html