Commercial Blues plans adopting the CMS do-not-pay list policy

April 1, 2010

In a move toward accountable care, the Blue Cross and Blue Shield Assn. (BCBSA) has established a policy that denies acute care hospitals reimbursement for certain never events.

NATIONAL REPORTS-In a move toward accountable care, the Blue Cross and Blue Shield Assn. (BCBSA) has established a policy that denies acute care hospitals reimbursement for certain never events. The policy went into effect January 1.

"Although some states had established legislation for hospitals to report never events, and some hospitals had agreed not to bill for them, approaches varied greatly," says Allan Korn, MD, chief medical officer and senior vice president for clinical affairs for the BCBSA. "To ensure consistency, as well as to demonstrate the Blues' commitment to quality healthcare, we created a consistent, systemwide approach to reimbursement for never events."

According to the National Quality Forum, a not-for-profit coalition of physicians, hospitals, businesses and policymakers, never events are preventable, costly errors. These include, for example, surgery performed on the wrong patient, the wrong body part or with the wrong device.

While never events are rare, they can be costly. BCBSA's focus this year is to work with providers to implement patient safety practices that are meaningful and measurable. The hope is that quality of care will become more efficient, minimizing mistakes and ultimately saving lives.

This alignment of patient safety and payment has been advancing for a few years. The BCBSA strategy began in 2007, and full implementation was phased in as contracts and agreements were renegotiated.

A number of Blue Cross and Blue Shield plans previously created their own policies regarding reimbursement for hospital-acquired conditions. The Blues systemwide policy, however, aligns with the Centers for Medicare & Medicaid Services (CMS) policy, which began refusing payment for never events in October 2008.

Patients will not be responsible for charges related to hospital-acquired conditions that the plans do not reimburse, and providers bear the financial cost of errors. Dr. Korn says the BCBSA did not experience pushback from providers when working with the association to implement the requirement.

Changing the relationship between healthcare delivery and reimbursement is part of the larger, national trend toward transparency and accountable care. With these changes, all stakeholders, providers, and insurers play a role in turning the tide on unnecessary deaths and injuries.

"The bigger focus is saving lives and improving the quality of care that people receive in the clinical setting," says Dr. Korn. "The real cost of such monumental errors can only be measured in terms of pain and suffering."

CMS had originally intended to include several more conditions on its do-not-pay list-for example, ventilator-assisted pneumonia and Legionnaire's disease-but backed down.

Hospital-acquired conditions addressed in the BCBSA policy include: