June 28, 2013
Last Revised Date:
June 26, 2015
All participating and nonparticipating acute care hospitals and ancillary providers that treat Horizon Blue Cross Blue Shield of New Jersey members.
To align Horizon BCBSNJ’s reimbursement policies with CMS and Blue Cross Blue Shield Association guidelines in regard to never events, including hospital acquired conditions and wrong surgeries.
Never Events : Adverse events or errors in medical care that are clearly identifiable, preventable and present serious consequences to patients. Includes hospital-acquired conditions and wrong surgeries.
Hospital Acquired Condition (HAC) : An illness or injury that was not present upon the patient's admission.
Wrong Surgery : A surgery performed on the wrong body part or patient; an entirely wrong procedure performed.
Horizon BCBSNJ follows CMS’ payment policy and will not reimburse hospitals or ancillary providers for any services related to wrong surgeries and may reduce payments to hospitals for services to treat hospital acquired conditions. Members will be held harmless for any reimbursement related to never events.
The Quality Management Department reviews system generated claim reports that contain certain codes that match CMS Never Event Indicators on a monthly basis. Hospital or ancillary provider documentation may be requested by a Horizon BCBSNJ Quality Auditor and reviewed in conjunction with other claims data to determine if a never event occurred. All identified never event occurrences are shared with the Hospital and Ancillary Contracting Departments.
The following never events are subject to review and identified through the diagnosis codes published by CMS annually. Horizon BCBSNJ will follow the most current CMS guidelines as to what constitutes a never event.
Hospital Acquired Conditions
- Foreign object retained after surgery.
- Air embolism.
- Blood incompatibility.
- Pressure ulcer stages III & IV.
- Falls and Trauma including fracture, dislocation, intracranial injury, crushing injury, burn and other injuries.
- Catheter-associated urinary tract infection (UTI).
- Vascular catheter-associated infection.
- Manifestation of poor glycemic control.
- Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG).
- Surgical site infection following certain orthopedic procedures.
- Surgical site infection following bariatric surgery for obesity.
- Surgical site infection following cardiac implantable electronic devise (CIED).
- Deep vein thrombosis and pulmonary embolism following certain orthopedic procures.
- Iatronic pneumothorax with venous catheterization.
- Surgery performed on a wrong body part
- Surgery performed on a wrong patient
- Wrong surgical procedure performed