RetiredCareSourcePolicy N/A

Provider Preventable Conditions (PPC) Policy for Arkansas PASSE

Governs reimbursement and reporting for provider-preventable conditions, including never events and healthcare-acquired conditions, for CareSource members in Arkansas PASSE programs and applies to participating providers.

Policy Summary

PayerCareSource

PolicyProvider Preventable Conditions (PPC) Policy for Arkansas PASSE

Policy CodePolicy N/A

Change TypeRetired (no material changes)

Effective DateSep 1, 2022

Next Review DateN/A

Key ActionWhen a never event occurs the provider shall neither bill, nor seek to collect from, nor accept any payment from CareSource or a member; any received payment must be refunded within ten business days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

09/01–12/31/2022policy active period

DMS-2704reporting form

NQF (29 events)reference standard

No payment for PPCsreimbursement stance

Coverage and Reimbursement Exclusions

Reimbursement exclusion and claim reduction rules

CareSource will not reimburse for services associated with never events, provider-preventable conditions (PPCs), or healthcare-acquired conditions (HCACs). Reimbursement may instead be reduced if the HCAC-related portion of a claim can be reasonably isolated per CMS guidance.

CareSource will not reimburse for services associated with never events, other provider preventable conditions, or healthcare-acquired conditions.

ALL of the following

When any never event occurs with respect to a member, the provider shall neither bill, nor seek to collect from, nor accept any payment from CareSource or a member for such events.
If the provider receives any payment from CareSource or a member for a never event, the provider shall refund payment to the member or entity making the payment within ten (10) business days of becoming aware of such receipt.

Policy Summary

PayerCareSource

PolicyProvider Preventable Conditions (PPC) Policy for Arkansas PASSE

Policy CodePolicy N/A

Change TypeRetired (no material changes)

Effective DateSep 1, 2022

Next Review DateN/A

SourceLink

On This Page

ALL of the following

CareSource does not reimburse providers for provider preventable conditions, including healthcare-acquired conditions, in accordance with CMS guidelines.
If HCAC portion identifiable
- If CareSource can reasonably identify and isolate the portion of the claim directly related to the treatment of the HCAC, CareSource will reduce reimbursement by the specific amount related to the provider preventable condition.
- The level of reimbursement reduction shall follow CMS's most recently published guidelines.

Examples (not exhaustive)

Surgical procedure or surgery performed on the wrong body part (wrong-site surgery).
Surgery performed on the wrong patient.
Wrong surgical procedure performed on a patient.
Unintended retention of a foreign object.
Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility.
Any instance of care ordered by or provided by someone impersonating a licensed healthcare provider.
Sexual abuse or assault on a patient or staff member within or on the grounds of a healthcare setting.
Death or serious injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of a healthcare setting.
HCAC examples including, but not limited to: Catheter Associated Urinary Tract Infections (CAUTI); Stage 3 or 4 pressure ulcers; surgical site infections; device- and procedure-related infections; deep vein thrombosis/pulmonary embolism following total knee or hip replacement (with pediatric and obstetric exceptions); falls and trauma; fractures; burns; and other listed conditions.

Provider Billing, Reporting, and Claim Adjustment Requirements

Billing Rule

Billing and refund obligation for never events

When a never event occurs the provider shall neither bill, seek to collect from, nor accept any payment from CareSource or a member. If the provider receives any payment for a never event, the provider shall refund payment to the member or entity making the payment within ten (10) business days of becoming aware of such receipt. The provider must also cooperate with CareSource, as reasonable, in initiatives to analyze or reduce never events.

Do not bill CareSource or the member for services associated with a never event.
If payment is received, refund payment within ten (10) business days of awareness.
Cooperate with CareSource’s reasonable initiatives to analyze or reduce never events.

Billing Rule

Claim adjustment when HCAC portion can be isolated

CareSource will not reimburse providers for healthcare-acquired conditions (HCACs). If CareSource can reasonably identify and isolate the portion of the claim directly related to the HCAC, CareSource will reduce reimbursement by the specific amount related to the provider preventable condition, with the level of reduction following CMS's most recently published guidelines.

CareSource will not reimburse for HCACs per CMS guidelines.
When the HCAC-related portion of a claim can be isolated, reimbursement will be reduced by the specific amount tied to the HCAC, following CMS guidance.

Documentation Required

Reporting provider preventable conditions (Form DMS-2704)

All PASSE providers must report provider preventable conditions associated with claims or member treatments using Form DMS-2704 (Adverse Events Notification) to the Division of Medical Services Reimbursement Unit. CareSource must track PPC data and submit a quarterly report that identifies all provider preventable conditions.

Report PPCs using Form DMS-2704 to the Division of Medical Services Reimbursement Unit.
CareSource will track PPC data and submit quarterly reports identifying all provider preventable conditions.

Key Definitions

Never Event

DefinitionSerious and costly errors in healthcare services that cause serious harm, injury, or death; unambiguous, clearly identifiable, measurable, and usually preventable.

Typical characteristicsAlso called preventable adverse events or sentinel events; result in death, loss of body part, disability, or more than transient loss of body function.

ScopeUsed for events that are feasible to include in a reporting system despite complexity of care and occasional nonavoidability.

Provider Preventable Condition (PPC)

DefinitionA condition occurring in any healthcare setting that is either a healthcare-acquired condition or another condition reasonably preventable by the provider through evidence-based procedures and that has a negative consequence for the member.

IncludesHealthcare Acquired Conditions (HCACs) and Other Provider Preventable Conditions (OPPCs).

Regulatory exampleOPPCs include wrong surgical/procedure on patient, wrong body part, or wrong patient per 42 CFR 447.26(b).

Healthcare Acquired Condition (HCAC)

DefinitionA medical condition or complication that a patient develops during a hospital stay which was not present on admission; aligns with Medicare's inpatient hospital-acquired conditions list.

ApplicationApplies to Medicaid inpatient hospital settings.

Relation to PPCConsidered a subset of Provider Preventable Conditions (PPCs).

OpenPayer

Provider Preventable Conditions (PPC) Policy for Arkansas PASSE

Coverage and Reimbursement Exclusions

Regulatory and Coding References

Provider Billing, Reporting, and Claim Adjustment Requirements

Key Definitions