Claims > Coverage Denied for Never Events
Beginning January 1, 2010, EmblemHealth will deny or adjust Medicare and Medicaid claims submitted for never events (defined as surgical or other invasive procedures performed in error by a practitioner or group of practitioners).
Surgical and other invasive procedures are defined as operative procedures in which skin or mucous membranes and connective tissue are cut into or an instrument is introduced through a natural body orifice. Procedures range from the minimally invasive to major surgeries. This applies to all procedures found in the surgery section of the Current Procedural Terminology (CPT) coding. It does not include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.
In general, never event errors include, but are not limited to:
- Performing a different procedure altogether
Any procedure that is not consistent with the correctly documented informed consent for the patient.
- Performing the correct procedure on the wrong body part
Any procedure that is not consistent with the correctly documented informed consent for the patient. This includes surgery on the appropriate body part, but in the wrong place (for example, operating on the left arm versus the right or on the left kidney not the right, or at the wrong level (spine).
- Performing the correct procedure on the wrong patient
Any procedure that is not consistent with the correctly documented informed consent for that patient.
All related services provided during the same hospitalization in which the error occurred are not covered. Medicare will also not cover other services related to these noncovered procedures as defined in the Medicare Benefit Policy Manual (BPM):
- All services provided in the operating room when such an error occurs
- Services rendered by any and all practitioners in the operating room when the error takes place who could bill individually for their services
Performance of the correct procedure after the never event has occurred is not considered a related service.
Note: Emergent situations that change the plan in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under the CMS ruling. This also includes the discovery of new pathologies near the surgery site, if the risk of a second surgery outweighs the benefit of patient consultation or the discovery of an unusual physical configuration (e.g., adhesions, extra vertebrae, etc.)
More information regarding Medicare never events and the latest rulings may be found on the CMS website at www.cms.gov.
Medicaid Never Events
The 13 avoidable hospital conditions that the New York State Department of Health has identified as non-reimbursable are:
- Surgery performed on the wrong body part
- Surgery performed on the wrong patient
- Wrong surgical procedure performed on a patient
- Patient disability associated with a medication error
- Patient disability associated with use of contaminated drugs, devices, biologics provided by a health care facility
- Patient disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
- Patient disability associated with an electric shock while being cared for in a health care facility
- Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by a toxic substance
- Patient disability associated with a burn incurred from any source while being cared for in a health care facility
- Patient disability associated with the use of restraints or bedrails while being cared for in a health care facility
- Retention of a foreign object in a patient after surgery or other procedure
- Patient disability associated with a reaction to administration of ABO-incompatible blood or blood products
- Patient disability associated with intravascular air embolism that occurs while being cared for in a health care facility
The Department of Health will continually review this list, which will be modified and expanded over time.
For those Medicaid cases where a serious adverse event occurs and the hospital anticipates at least partial payment for the admission, the hospital will follow a two-step process for billing the admission:
- The hospital will first submit their claim for the entire stay in the usual manner, using the appropriate rate code (i.e., rate code 2946 for DRG claims or the appropriate exempt unit per diem rate code such as 2852 for psychiatric care, etc.). That claim will be processed in the normal manner and the provider will receive full payment for the case.
- Once remittance for the initial claim is received, it will be necessary for the hospital to then submit an adjustment transaction to the original paid claim using one of the following two new rate codes associated with identification of claims with serious adverse events:
- 2591 (DRG with serious adverse events), or
- 2592 (Per Diem with serious adverse events)
All claims identified as never events will be reviewed on a case by case basis.
Glossary terms found on this page:
An activity of EmblemHealth or its subcontractor that results in:
- Denial or limited authorization of a service authorization request, including the type or level of service
- Reduction, suspension or termination of a previously authorized service
- Denial, in whole or in part, of payment for a service
- Failure to provide services in a timely manner
- Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals
Formal acceptance as an inpatient by an institution, hospital or health care facility.
An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
The government agency responsible for administering the Medicare and Medicaid programs.
Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.
A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.
An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:
- Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
- Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
- Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
- Maintains medical records for all patients
- Has a requirement that every patient be under the care of a member of the medical staff
- Provides 24-hour patient services
- Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements
An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called NYSDOH.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.