Effective December 1, 2010, Blue Cross and Blue Shield of Texas (BCBSTX) will apply the following principles and guidelines for review and determination of Hospital Acquired Conditions (identified by CMS) and Never Events (identified by National Quality Form), to determine whether reimbursement to a physician or other professional provider should be reduced for the additional costs related to the event.

• The error or event must be preventable.
• The error or event must be within control of the physician or other professional provider.
• The error or event must be a result of a mistake by the physician or other professional provider.
• The error or event must result in significant harm.
• Identification of non-payable events will incorporate case-by-case review and determination by a BCBSTX Medical Director, except when self reported and without dispute.

If medical records are required to complete a review of a Hospital Acquired Condition/Never Event, the minimum defined record set will include: Discharge Summary, Admission History and Physical, Operative Reports, Consultation Reports, Physician Progress Notes, Emergency Department records (if admitted via the ER), and other documentation as determined by the Medical Director.

If adjustment of claims is determined applicable, the physician or other professional provider will be notified. The physician or other professional provider may appeal a decision made by BCBSTX for the Hospital Acquired Condition/Never Event and appeal instructions will be included in the notification letter.

Hospital Acquired Conditions

As defined by CMS, Hospital Acquired Conditions are those conditions that are acquired by a patient while they are in the inpatient hospital setting and were not present upon admission to the hospital.

The following Hospital Acquired Condition represents a potential area of responsibility and will be reviewed by a BCBSTX Medical Director on a case by case basis:

1. Foreign Object Retained After Surgery

Never Events

As defined by the National Quality Forum (NQF), Never Events are adverse events that are serious, but largely preventable, and of concern to both the public and health care providers for purposes of public accounting. Never Events earned that name because these events should never happen in medical practice.

The following Never Events represent potential areas of responsibility and will be reviewed by a BCBSTX Medical Director on a case by case basis:

1. Surgery performed on the wrong body part
2. Surgery performed on the wrong patient
3. The wrong surgical procedure performed on a patient

Should you have any questions, contact your local Professional Provider Network office.

posted 07/2010