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Things Medicare Will Not Pay For

  • Date: 2010/12/18 (Rev. 2016/10/19)
  • Wood and Carlton PC - woodcarltonishee.com
  • Synopsis : New policy to stop paying for medical care needed to correct medical mistakes that occur while patients stay in hospitals.

Main Document

In 2008 the Centers for Medicare and Medicaid Services (CMS) adopted a new policy to stop paying for medical care needed to correct medical mistakes that occur while patients stay in hospitals.

Medicare called these events "never events" because they are so egregious that they should never happen. Some of these events include:

  • Catheter-associated urinary tract infections and vascular infections
  • Falls in the hospital
  • Foreign objects left in the body after surgery, like sponges
  • Infections
  • Post-surgical blood clots
  • Post-surgical pneumonia
  • Wrong-site operations (i.e. operating on the wrong body part)
  • Wrong type blood transfusions

Bed sores, also referred to as "pressure sores" or "pressure ulcers" are another never event that Medicare will not reimburse hospitals or physicians for treating. Patients develop bed sores when they lie for long periods of time in the same position. The skin and tissue begins to break down and eventually will die because the constant pressure exerted on it breaks off blood flow. The areas on the body most prone to the development of bed sores include the hips, buttocks and heels.

While bed sores can develop and become very serious very quickly, they also are easy to prevent. For patients who are paralyzed, bedridden after surgery or who are too sick to move themselves, nurses and other hospital staff members must do it for them to prevent the development of the painful ulcers. Unfortunately, this does not always happen and patients suffer as a result.

If a patient develops a bed sore or other complication included on the list of never events, the hospital and/or physician will not receive reimbursement from Medicare for treatment to correct the condition. Additionally, Medicare has prohibited the hospital from seeking payment for the services from the patient. Some private insurers have followed Medicare's example and have adopted their own lists of never events they will not pay for. In some cases these lists are more extensive than Medicare's.

Policy Meant to Improve Patient Care

The purpose of Medicare's change in policy was to improve patient care and reduce the number of preventable medical errors occurring in hospitals across the country. A 1999 study found that medical errors are responsible for nearly 100,000 deaths each year in the US and cost the country more than $29 billion annually. Medicare, which pays out more than $110 billion in annual reimbursements to US hospitals, estimated it would save up to $21 million each year by refusing to pay for the 500,000+ follow-up procedures necessary to correct never events.

Health care professionals, however, have argued that the policy may not have its intended effect. While physicians agree that some of the errors Medicare will not pay for truly should never happen - like wrong site surgeries and wrong type blood transfusions - some of the other events are simply risks of medical procedures that even the best medical care will not always be able to prevent. These events include post-surgical infections, blood clots and urinary tract infections. Health care professionals have argued that the emphasis should be placed on preventing never events from happening altogether rather than not paying for them when they do.

Contact an Experienced Medical Malpractice Attorney

Even with Medicare's growing list of never events, preventable medical errors still happen. In some cases, patients who have been the victim of a hospital, surgical or other medical error may have legal options available to them.

Hospitals and physicians owe important duties to patients, including the duty to provide them with treatment that meets the prevailing standard of care. If the medical mistake was the result of negligence on the part of the physician or hospital employee, then the patient has the right to bring a malpractice claim. Some of the types of compensation that may be available to injured patients who successfully bring a medical malpractice claim include past and future medical expenses, rehabilitation costs, lost wages, loss of earning capacity and damages for pain and suffering.

For more information on your legal options, contact an experienced medical malpractice lawyer today. An attorney can review your case and help you determine the best way to proceed.




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