The Deficit Reduction Act of 2005 (DRA) overhauled Medicare’s perspective on payment for medical care related to “never events” including a list of delineated hospital acquired conditions. Hospitals will no longer receive reimbursement for conditions that are (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. The ten categories for hospital acquired conditions are: Foreign Object Retained After Surgery,.Air Embolism,,Blood Incompatibility, Stage III and IV Pressure Ulcers, Falls and Trauma including, Fractures, Dislocations, Intracranial Injuries, Crushing Injuries, Burns and Electric Shock, Manifestations of Poor Glycemic Control including, Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis and Secondary Diabetes with Hyperosmolarity, Catheter-Associated Urinary Tract Infection, Vascular Catheter-Associated Infection, Surgical Site Infection Following Coronary Artery Bypass Graft (CABG) – Mediastinitis, Bariatric Surgery, Laparoscopic Gastric Bypass, Gastroenterostomy, Laparoscopic Gastric Restrictive Surgery, Orthopedic Procedures and Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE).
While the Centers for Medicare and Medicaid Services (CMS) have prohibited hospitals from recovering payment for the treatment of secondary conditions acquired in the hospital, practically, these charges are often submitted and paid by Medicare long before and attorney becomes involved and makes a claim for medical malpractice. Careful examination of the supporting documentation Medicare provides at the time they require reimbursement often reveals that benefits were paid for hospital acquired events.