Payment Matters: CMS Proposes Rule for Medicaid Nonpayment in the Event of Health Care Acquired Conditions


CMS has released a proposed rule, which would implement the Affordable Care Act’s requirement that state Medicaid plans must disallow payment for care and services related to health care acquired conditions (HCACs) and other provider-preventable conditions (OPPCs). The proposed rule would require states to adopt Medicare’s existing payment prohibitions for hospital acquired conditions, and would extend those prohibitions to conditions acquired by Medicaid beneficiaries in non-hospital settings. Under the proposed rule, states would be required to establish a provider self-reporting mechanism for HCACs and OPPCs.

Health professionals that treat Medicaid patients should familiarize themselves with the list of hospital acquired conditions, which all state Medicaid plans would target for nonpayment under the proposed rule. The current list of hospital acquired conditions may be viewed here (see full alert below for link). States would also be able to establish OPPCs based on the following criteria: the condition or event must be (1) discrete, auditable, quantifiable, and clearly defined; (2) clearly adverse, resulting in negative consequence of care that results in unintended injury or illness; and (3) reasonably preventable, meaning an event that could have been anticipated and prepared for, but that occurs because of an error or other system failure.

Comments must be received no later than March 18, 2011.

Please see full alert below for more information.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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