Harmful Event Detection Misses Problems, Results in Medicare Overpayments, Says OIG

Medicare no longer pays higher reimbursement for hospitalizations complicated by the 10 conditions that were not present upon admission: Retention of foreign surgical object, air embolism, blood incompatibility, pressure ulcers, falls, poor glycemic control, catheter-associated urinary tract infections and vascular catheter-associated infections, deep vein thrombosis or pulmonary embolism associated with total knee or hip replacement, and surgical site infection.

In order to receive payment for the care of Medicare and Medicaid patients, hospitals are required by law to develop and maintain quality assessment and performance improvement (QAPI) programs.

In doing so, they must "track medical errors and adverse patient events, analyze their causes and implement preventive action and mechanisms that include feedback and learning throughout the hospital," the OIG report said.

The OIG issued four recommendations to more diligently track and prevent adverse events.

1. CMS and the Agency for Healthcare Research and Quality should explore opportunities to identify events when conducting medical record reviews for other purposes. For example, adverse event searches could be conducted during CMS' Medicare Comprehensive Error Rate Testing, and during work of Quality Improvement Organizations. Also, state surveys conducted to identify hospital compliance with Medicare conditions of participation may detect problems in care.


2. CMS should ensure that hospitals code claims accurately and completely to allow for identification of hospital acquired conditions affected by Medicare's payment policy.


3. CMS should provide interpretive guidelines for state survey agencies to assess hospital compliance with requirements to track and monitor events.  CMS should provide guidance to surveyors for assessing hospitals' compliance. Such guidance could include what types of medical errors and adverse patient events hospitals should track and monitor, as well as what information should be captured in hospital incident reports.


4. AHRQ should inform patient safety organizations that internal hospital incident reporting may be insufficient to provide needed information.