Medicaid will no Longer Pay for Preventable Events
July 20, 2011 – In late May, CMS passed a final rule announcing that hospitals and healthcare providers will no longer be reimbursed for treating their Medicaid patients for illnesses, injuries, or readmissions that should have been prevented. This rule enacts a portion of the Affordable Care Act (ACA) that prohibits States from making Medicaid payments to providers for conditions that are deemed “reasonably preventable.”
In 2008, Medicare stopped reimbursing hospitals for treating conditions, infections, or illnesses that were acquired in the hospital, and for any readmissions associated with treating those hospital-acquired conditions.
The Medicaid list of preventable conditions mirrors the Medicare list including:
- Transfusing the wrong blood type
- Falls that result in dislocation, fractures, or head injuries
- Burns and electric shocks
- Catheter-associated urinary tract infections
- Surgical site infections after bariatric surgery or coronary artery by pass; and
- Manifestations of poor glycemic control
CMS has also issued National Coverage Decisions stating that Medicare will not pay for certain “never events” – those which should never happen—including performing the wrong procedure; performing the procedure on the wrong body part, or performing the correct procedure, but on the wrong patient. Medicaid will also not pay for these events.
States can identify additional preventable conditions for which Medicaid payments will be denied. The final rule is effective July 1, 2011, but gives States the option to implement these changes up through July 1, 2012.
Some private carriers have followed Medicare’s lead in not paying for “preventable events” and “never events.”
Tags: CMS Updates
