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November 2014

Reminder: Hospital reimbursement policy for serious adverse events

As you’ve read previously in The Record, Blue Cross Blue Shield of Michigan and Blue Care Network developed a hospital reimbursement policy for serious adverse events. It has been in effect since Oct. 1, 2008.

Serious adverse events are reasonably preventable conditions that result from medical errors in the hospital or improper hospital care.

Consistent with the Centers for Medicare & Medicaid rulings for discharges on or after Oct. 1, 2008, Blue Cross and BCN do not pay hospitals and physicians for costs incurred when treating a condition that resulting from a serious adverse event.

Note: CMS refers to a serious adverse condition as an HAC, which stands for hospital-acquired condition.

The policy also is consistent with Blue Cross’ existing reimbursement structure under our participating hospital agreements and other health care provider contracts. These agreements and contracts don’t allow payment for medically unnecessary services, regardless of the cause.

Background
Effective Oct. 1, 2008, Blue Cross and Blue Care Network applied the new policy across all health plans. Provisions of the policy include the following:

  • Blue Cross and Blue Care Network will no longer reimburse a hospital or physician for costs associated with direct actions resulting in a serious adverse event.
  • Serious adverse events covered under the Blue Cross policy are consistent with CMS policy payment for an HAC.
  • Participating hospitals are required to report a “present on admission” indicator for all claims.
  • Participating hospital and physicians may not “balance bill” members for any incremental costs associated with treatment of a serious adverse event. This policy can’t be changed by any customer.

Submitting codes for serious adverse events
Keep in mind that you must report the appropriate codes for serious adverse events. CMS updates the list yearly. For more information, visit CMS.gov** and type “hospital acquired conditions” in the search bar.

**BCBSM does not control this website or endorse its general content.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.