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Aetna and WellPoint Refuse to Pay for Medical Errors
By Staff Writers
According to The Wall Street Journal, some large private health insurers are following Medicare’s lead by refusing reimbursement for erroneous medical care. Aetna and WellPoint now have contract provisions stating their refusal to pay – or allow patient-balance-billing – for care related to the 28 “Never-Events” compiled by the National Quality Forum [NQF].
These NEs include, death of a low-risk pregnancy mother, instruments left in-situ after surgery, and using contaminated instruments or medical devices. Of course, the very definition of some other NEs is hotly contested.
Significant Examples
Nevertheless, Aetna is including contract provisions that bar payment for all 28 NEs. And, WellPoint is refusing payment for 4/28 NEs in the State of Virginia.
Other insurers, like UnitedHealth Group and Cigna are considering similar moves; as are all 39 members of the Blue Cross/Shield Association. Hospitals in Minnesota and Massachusetts have already agreed to not charge for all, or at least some, of the 28 never events identified by the NQF.
Assessment
And so, is this a national economic trend whose time has come; or just an unfortunate quality-care issue gone wrong regarding the “law of unintended consequences?” What are your thoughts?
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Filed under: Healthcare Finance, Quality Initiatives | Tagged: Health Law & Policy |
The Leading Business Education Network for Doctors, Financial Advisors and Health Industry Consultants 
Pennsylvania’s hospitals announced yesterday that they will not charge for care related to serious medical mistakes such as wrong-body-part surgery and substantial medication errors.
The announcement follows similar stands by hospitals in Massachusetts and Minnesota, as noted on this blog and elsewhere. But, it only applies to patients who are on public healthcare coverage, like the PA Medical Assistance program. The move, was announced by the Hospital & Health System Association of Pennsylvania
QUERY: And so, am I to pay for mistakes and NEs because I am employed and have private health insurance overage – please opine – help me understand – and explain?
-Cindy, RN
As Dr. Phil would say; “is the word STUPID stamped on my forehead?”
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Brief Historical Review of the “Never-Events” policy
The National Quality Forum’s [NQF] list of 28 Serious Reportable Events (sometimes called “never events” – medical errors that should never happen to a patient), is not exactly new.
In fact, was initiated in 2006; prompting the Leapfrog Group to give public recognition to hospitals that agree certain steps should be taken whenever a serious reportable adverse event occurs in their facility.
Through the 2007 Leapfrog Hospital Quality and Safety Survey, hospitals will be given the opportunity to receive public recognition for agreeing to do the following if a “never event” occurs within their facility:
• Apologize to the patient and/or family affected by the never event.
• Report the event to one organization; ie., JCAHO, state program or Patient Safety Org.
• Perform a root cause analysis, consistent with the chosen reporting program.
• Waive all costs directly related to the NE and refrain from seeking reimbursement from the patient or a third party payer.
Of course, the issue is ever evolving as reported in the Executive Post.
Source: Leapfrog Group, November 15, 2006
-Linda
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Who Foots the Bill for Medical Errors?
Another interesting and related post on Never-Events.
http://www.msnbc.msn.com/id/23341360
Best
-Hope
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I am taking a healthcare policy class and need information on the development of a “never-events” policy. Do you know where to go for this?
Thanks.
Shannon Hoy
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Cindy, Linda, Hope and Shannon
Are “Never-Events” No-Pay Policies Gaining Ground? You bet!
Aetna just announced confirmaton of the new policy noted above, that refuses to pay for care related to a group of 28 adverse events, and require medical providers to take a series of reporting and corrective steps to address the errors.
Link: http://www.fiercehealthfinance.com/story/aetna-refuses-payment-never-events-requires-corrective-action/2009-08-26?utm_medium=nl&utm_source=internal
You are correct to ask how many other insurance companies will follow this lead, and when?
Graham
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Wrong Sided Hand Surgery
The fifth time is the charm:
http://www.msnbc.msn.com/id/33470674/ns/health-health_care
Adam
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Preventable Death-List Watch
The US ranks at the bottom of 19 industrialized countries in preventable deaths.
The Washington Post just reported on a study by the Commonwealth Fund published in the journal Health Affairs, that the United States ranks at the bottom of 19 industrialized nations in the number of preventable deaths by conditions such as diabetes, epilepsy, stroke, influenza, ulcers, pneumonia, infant mortality and appendicitis.
Rank Country Preventable deaths per 100,000 population in 2002-2003
1 France 65
2 Japan 71
3 Australia 71
4 Spain 74
5 Italy 74
6 Canada 77
7 Norway 80
8 Netherlands 82
9 Sweden 82
10 Greece 84
11 Austria 84
12 Germany 90
13 Finland 93
14 New Zealand 96
15 Denmark 101
16 UK 103
17 Ireland 103
18 Portugal 104
19 US 110
Data Source: Commonwealth Fund, Health Affairs, World Health Organization
Publication: The Washington Post, U.S. Losing Ground on Preventable Deaths, October 6, 2009. http://www.washingtonpost.com/wp-dyn/content/article/2009/10/05/AR2009100503798.html
Victor
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Victor,
Many thanks for the link above. Now, please allow me to offer you, and all ME-P readers, this one. It sould be titled: [Mis] Adventures in Cardiology
http://adventuresincardiology.com/
From Johns Hopkins Hospital, in Baltimore, no less!
Shamus
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Never Events and Non-Payments
Medicare and private insurers thought they were doing the right thing over the past two years by refusing to pay for additional hospital care for what they consider hospital-acquired conditions.
But, some critics say that while their intentions are worthy, such do-not-pay policies haven’t worked in reducing these conditions, and payers should try some new approaches.
http://www.fiercehealthpayer.com/story/guest-commentary-cms-no-pay-policy-hasnt-reduced-hospital-acquired-conditions/2010-08-16?utm_medium=nl&utm_source=internal
What do ME-P readers think?
Amy
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CMS Bars Medicaid Payments For Preventable Conditions
Beginning on July 1, 2011, CMS will deny all Medicaid reimbursement requests associated with provider-preventable conditions, known as never events, reflecting a recent trend of payment policies aimed at lowering healthcare costs and increasing quality.
The final rule, published June 6, 2011, implements Section 2702 of the ACA, and gives states one year to amend their individual Medicaid legislation for compliance.
Click to access cms.pdf
Ann Miller RN MHA
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Update: N-Es
On never-say-never events … again, by colleague Bob Wachter MD!
http://community.the-hospitalist.org/2011/06/30/never-say-never-events/
Hope Rachel Hetico RN MHA
http://www.HealthcareFinancials.com
[Managing Editor]
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N-Es
The November issue of H&HN [Hospitals and Health Networks] just published an article on wrong site surgery, but I read about it on the ME-P first.
Terry
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Process Improvement to Lower Surgery Risks
Using Robust Process Improvement methods, several pilot hospitals and ambulatory surgical centers partnered with the Joint Commission to significantly reduce the number of surgical cases with risks and helped to develop a Targeted Solutions Tool™ for Wrong-Site Surgery.
http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=7770007102
Yep; technology rather than common sense!
Adam
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