April 17, 2008 | Mark Paradies

Another Insurer Says They Won’t Pay for Medical Mistakes…

A press release from Cigna:

As part of its ongoing focus on improving health care quality, CIGNA HealthCare is taking steps to stop reimbursing hospitals for so-called “never events” and avoidable hospital conditions, which are errors in patient care that can and should be prevented. CIGNA’s new policy is consistent with and based on the policy of the Centers for Medicare and Medicaid Services (CMS), and both policies will become effective on Oct. 1, 2008.

“CIGNA is committed to improving quality for our members throughout the health care system,” said Jeff Kang, MD, chief medical officer for CIGNA HealthCare. “Our policy on never events and avoidable hospital conditions is designed to put patient safety first and to encourage hospitals to improve quality every day, one patient at a time.”

“We commend CIGNA for its commitment to patient safety and quality improvement,” said Helen Darling, president of the National Business Group on Health. “Hospitals, health care professionals and health plans must all work together to ensure that ‘never events’ never happen, avoidable conditions are always avoided, and every patient receives quality treatment in a safe and caring environment.”

As defined in CIGNA’s policy, “never events” are surgical procedures that are performed on the wrong side, wrong site, wrong body part or wrong person. They earned that name because they should never happen in medical practice. For example, surgery erroneously performed on the right knee instead of the left knee, or the erroneous removal of a gall bladder instead of an appendix, are considered to be never events.

CIGNA will not reimburse for never events because they are not “medically necessary.” Surgery performed on the wrong side, wrong site, wrong body part or wrong person is not considered medically necessary to diagnose or treat an illness, injury or disease, and is therefore not reimbursable.

An avoidable hospital condition (also known as an acquired hospital condition) is one that a patient does not have when admitted to the hospital, develops during the patient’s hospital stay, and could have been avoided if the hospital had followed evidence-based guidelines and best practices for patient care.

Consistent with CMS policy, the avoidable hospital conditions that CIGNA has identified as potentially non-reimbursable are: objects left inside a patient during surgery; air embolism, or sudden artery blockage from air bubbles introduced during surgery; use of the wrong blood type during transfusions; infections from urinary catheters; pressure ulcers, also known as bed sores; infections from central vein catheters; mediastinitis, an often fatal inflammation in lung tissue; and hospital-acquired injuries, such as fractures, dislocations, and burns.

CIGNA will stop reimbursement for these avoidable hospital conditions when permitted under its hospital contracts. For example, if a patient receives the wrong blood type during a transfusion, or a surgical instrument is left inside a patient during surgery, and that error prolongs the patient’s hospital stay by two days, CIGNA would deny reimbursement to the hospital for the additional two days when permitted by contract. CIGNA’s policy is designed to avoid member liability for any payment denials to participating facilities.

The policy is consistent with CIGNA’s participation in or support for a number of national quality organizations and initiatives, including the National Quality Forum and the Leapfrog Group. CIGNA encourages hospitals to adopt the Leapfrog guidelines on never events, which call for hospitals to apologize to the patient and family affected by a never event; report the event to at least one agency, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); perform a root cause analysis of the event; and waive all costs directly related to the event.

CIGNA provides measures of hospital quality through its Provider Directory on www.cigna.com. When hospitals adopt the Leapfrog guidelines they may receive a higher quality rating. The company plans to enhance its hospital quality ratings by giving greater weight to never events and avoidable hospital conditions once the new policy is implemented.

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