CurrentHealth-New-EnglandPolicy N/A

Serious Reportable Events and Never Events

Defines reporting, reimbursement, and scope for Serious Reportable Events (SREs) and Never Events for Health New England members and affected providers and facilities; applies to inpatient and outpatient settings where HNE members receive care.

Policy Summary

PayerHealth-New-England

PolicySerious Reportable Events and Never Events

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionProviders must waive member cost-sharing and must fax the Massachusetts DPH report to Health New England Utilization Review Specialist at 413-233-2700 when an SRE/Never Event involves an HNE member.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

29SRE/Never Events (NQF)

10Non-reimbursable examples

2009-01-01Non-payment effective

413-233-2700HNE reporting fax

Reimbursement Stance and Provider Obligations

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Non-reimbursement stance and provider obligations

HNE will not reimburse for services associated with specified Serious Reportable Events (SREs) and Never Events and requires providers to waive member cost-sharing for the admission during which such an event occurred.

Reimbursement prohibition applies to services associated with listed Serious Reportable Events and Never Events (effective January 1, 2009).

Examples of non-reimbursable events

Surgery on the wrong body part
Surgery on the wrong patient
Wrong surgical procedure
Retention of foreign object
Incompatible blood-associated injury
Air embolism-associated injury
Medication error injury
Artificial insemination/wrong donor
Infant discharged to wrong family

Providers shall not bill HNE members for charges associated with the SREs/Never Events for which HNE denies reimbursement, and for any subsequent care needed to address the events.

Providers must waive any copay or deductible due from the HNE member for the admission during which the Serious Reportable Event or Never Event occurred.

HNE may retract payment for services after payment if the claim is identified as meeting non-reimbursement criteria for an SRE or Never Event; the Medical Director and Health Services Department may review claims to determine whether to extend non-payment to other service professionals when notified.

Policy scope: applies to all facilities (hospitals, rehab centers, skilled nursing, visiting nurse associations, same day surgery centers, offices, and outpatient locations), in-network and out-of-network, and may be amended or expanded by HNE.

Claim Coding and POA Requirements

POA and claim coding requirementsmixed

No codes listed

Present on Admission (POA) indicator requirement

POA indicator requirementPresent on Admission (POA) indicators must be provided on all inpatient claims.

Consequence for missing POAFailure to indicate POA conditions on an inpatient claim may result in delayed reimbursement or denial of the claim.

PurposePOA reporting supports identification of inefficient care and preventable conditions.

Reporting, Billing, and Recoupment Requirements

Documentation Required

Simultaneous reporting to HNE (fax required)

Facilities required to report a Serious Reportable Event or Never Event to the Massachusetts Department of Public Health must simultaneously fax a copy of the DPH report (per DPH Circular Letter DHCQ-08-07-496) to the Health New England Utilization Review Specialist at fax number 413-233-2700 when the event involves an HNE member.

Billing Rule

Do not bill members; waive member cost-sharing

Providers shall not bill Health New England members for charges associated with Serious Reportable Events or Never Events for which HNE denies reimbursement, including any subsequent care needed to address the events. Providers must waive any copay or deductible owed by the HNE member for the admission during which the event occurred.

Billing Rule

Post-payment recoupment for identified SREs/Never Events

Health New England will retract payment for any services after payment if the claim is later identified as meeting the policy's non-reimbursement criteria for a Serious Reportable Event or Never Event.

Key Definitions

Serious Reportable Event (SRE)

DefinitionA Serious Reportable Event is an event that results in a serious adverse patient outcome that is clearly identifiable and measurable, reasonably preventable, and caused by care management, or errors that occur from failure to follow standard care or institutional practices and policies.

ScopeIncludes events identified by the National Quality Forum across seven categories (e.g., Surgical or Invasive Procedure Events; Product or Device Events; Patient Protection Events).

CountThe NQF has identified 29 Serious Reportable Events and Never Events.

Never Event

DefinitionNever Event: any wrong procedure(s) performed on the wrong side, wrong body part, or wrong person.

Medical necessity statusAll Never Events involving a wrong procedure on the wrong side/body part/person are considered not medically necessary.

ImplicationSuch events are not required to diagnose or treat an illness, injury, disease or its symptoms and are inconsistent with generally accepted standards of medical practice.