Application: Medicare and a Never-Event Involving a Patient Transfer Case
The Centers for Medicare and Medicaid Services (CMS) have identified pressure ulcers, or bedsores, as one of the hospital-acquired conditions, or “never events,” that they will not reimburse at the normal rate under Medicare. Pressure ulcers develop over time. One challenge facing health care administrators and providers is getting proper reimbursement for their services in cases of patient transfer if the patient’s conditions were acquired elsewhere.
For this Application you will analyze the legal, financial, and ethical considerations of a case involving patient transfer, based on the following scenario:
A Medicare patient is admitted from a skilled nursing facility for dehydration. There is a close clinical relationship between the facilities, with admissions and services at both facilities referred to each other. A day or two after admission, a pressure ulcer is assessed. There is concern at the hospital about whether they will be paid for this condition.
The hospital staff claims that the pressure sore was caused by the local skilled nursing facility. The skilled nursing facility did not document any skin issues prior to discharge and believes the hospital is blaming it for the hospital’s poor skin care.
As an administrator in this hospital, you would naturally want to get reimbursed for the care now required to treat this patient’s pressure ulcer, to prevent this kind of issue from happening in the future, and also to maintain good organizational ties with this skilled nursing facility.
To prepare for this Application Assignment, complete the following:
Review textbooks in previous courses, such as the excerpts listed in this week’s Optional Resources, or do online research to remind yourself of Medicare payment policies regarding “never events.” Reflect on the ethical implications of Medicare’s “never events” policy. What challenges would you expect to occur regarding who ends up paying for never-event conditions and the impact on quality of care?
Do online research to learn more about pressure ulcers. What causes them and what kind of care is required to treat them?
Review the consequences of false claims, as described in this week’s Learning Resources.
Think through various ways in which an administrator could institute policies to help prevent or mitigate situations such as the one described above.
The Application Assignment:
With these thoughts in mind, write a 3- to 4-page paper in which you address the following questions:
What are the factors (e.g., timely and appropriate clinical services) that determine whether patients at risk for pressure ulcers receive proper skin care?
What does administration need to do to ensure that the hospital is not submitting claims for services for which payment is not available under applicable rules? Take into account the role of individuals who may want to become a whistleblower, or qui tam relator, under the False Claims Act.
Legally, how did CMS go about deciding that it would reduce reimbursement for hospital-acquired pressure ulcers and other conditions? Does this policy make sense to you? Why? Does the policy raise any ethical issues?
In what ways might an administrator alter systems to avoid the adverse conditions impacting payment, as described in this scenario? In particular, what, if anything, might a hospital administrator do regarding the skilled nursing facility from which this and other patients come?
This 3- to 4-page Application Assignment is due by Day 7 of this week.
Your written assignment must follow APA guidelines. Be sure to support your work with specific citations from this weeks’ Learning Resources and additional scholarly sources as appropriate. Refer to the Essential Guide to APA Style for Walden Students to ensure your in-text citations and reference list are correct.
Course Text: Legal and Ethical Issues for Health Professionals
Chapter 7, “Government, Ethics, and the Law”
This chapter describes the role of the U.S. Office of Government Ethics in relation to health care, and outlines key laws involving admission (e.g., EMTALA), antitrust, and other laws associated with interagency relationships or obligations related to government funding.
Course Text: Legal Essentials of Health Care Administration
Chapter 5, “Criminal Aspects of Health Care”
Chapter 17, “Legal Reporting Requirements”
Chapter 29, “National Health Insurance and Managed Care”
Criminal law is described in Chapter 5, including sections outlining patient abuse, false claims, kickbacks, and fraud. Health care organizations are required by law to document and report a variety of measures, generally in connection with public health and safety. Chapter 17 describes these and also explains corporate compliance programs.
Legal aspects of managed care organizations (MCOs), mergers, and the restructuring of more traditional health care organizations are discussed in Chapter 19. Also included is an explanation of price-fixing, which is a violation of antitrust laws.
Statute: False Claims Act, 31 U.S.C. § 3729. Retrieved November 23, 2009, from http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD032207Att2.pdf
HHS: Office of Inspector General (OIG): Fraud Prevention and Detection
OIG Fact Sheet: Federal Anti-Kickback Law and Regulatory Safe Harbors
National Association of Medicaid Fraud Control Units: NAMFCU Participating States
Course Text: Cleverley, W. O., & Cameron, A. E. (2007). Essentials of health care finance (6th ed.). Sudbury, MA: Jones and Bartlett. (MHA 6160 course text)
Chapter 4, “Legal and Regulatory Environment”
See especially pages 90–94 on anti-kickback statutes and safe harbor.
Course Text: Essentials of Health Policy and Law
Chapter 4, “Understanding Health Insurance”
Article: Rothman, D. J. (2008). Academic medical centers and financial conflicts of interest. JAMA: Journal of the American Medical Association, 299(6), 695–697. Retrieved from http://jama.jamanetwork.com.ezp.waldenulibrary.org/data/Journals/JAMA/4404/jed80003_695_697.pdf
Web Site: ACHE Policy Statement: Considerations for Healthcare Executive-Supplier Interactions