Application Medicare And A Never Event Involving A Patient

Application Medicare And A Never Event Involving A Patient Transfer C

Review textbooks in previous courses, such as the excerpts listed in this week's Optional Resources, or do online research to remind yourself of Medicare payment policies regarding "never events." Reflect on the ethical implications of Medicare's "never events" policy. What challenges would you expect to occur regarding who ends up paying for never-event conditions and the impact on quality of care?

Do online research to learn more about pressure ulcers. What causes them and what kind of care is required to treat them? Review the consequences of false claims, as described in this week's Learning Resources. Think through various ways in which an administrator could institute policies to help prevent or mitigate situations such as the one described above. The Application Assignment: With these thoughts in mind, write a 3- to 4-page paper in which you address the following questions: What are the factors (e.g., timely and appropriate clinical services) that determine whether patients at risk for pressure ulcers receive proper skin care?

What does administration need to do to ensure that the hospital is not submitting claims for services for which payment is not available under applicable rules? Take into account the role of individuals who may want to become a whistleblower, or qui tam relator, under the False Claims Act. Legally, how did CMS go about deciding that it would reduce reimbursement for hospital-acquired pressure ulcers and other conditions? Does this policy make sense to you? Why?

Does the policy raise any ethical issues? In what ways might an administrator alter systems to avoid the adverse conditions impacting payment, as described in this scenario? In particular, what, if anything, might a hospital administrator do regarding the skilled nursing facility from which this and other patients come? This 3- to 4-page Application Assignment is due by Day 7 of this week. Your written assignment must follow APA guidelines.

Be sure to support your work with specific citations from this week's Learning Resources and additional scholarly sources as appropriate. Refer to the Essential Guide to APA Style for Walden Students to ensure your in-text citations and reference list are correct.

Paper For Above instruction

The case involving a pressure ulcer acquired during a patient transfer from a skilled nursing facility (SNF) to a hospital highlights complex legal, financial, and ethical challenges faced by healthcare administrators. The Medicare program's policy to deny reimbursement for hospital-acquired pressure ulcers, classified as "never events," aims to incentivize hospitals to improve patient safety and care quality. However, this policy also introduces dilemmas concerning accountability, resource allocation, and ethical care delivery, especially in scenarios involving interfacility transfers.

Fundamentally, the determination of appropriate skin care for at-risk patients hinges on timely, comprehensive assessments and the implementation of preventive measures. Patients identified as at risk for pressure ulcers—due to immobility, poor nutrition, or underlying health conditions—must receive individualized skin assessments, frequent repositioning, nutrition management, and use of pressure-relieving devices (Rafter et al., 2014). The hospital must ensure that clinical protocols are strictly followed, staffing adequately trained, and documentation meticulously maintained to provide evidence of preventative care, which also protects against false claims or reimbursement denials.

Administrators bear the responsibility of establishing policies that support high-quality care and compliance with Medicare regulations. This involves rigorous documentation, adherence to clinical guidelines, and continuous staff education. To avoid submitting false claims, hospitals must verify that conditions such as pressure ulcers are accurately documented, non-preventable when appropriate, and supported by thorough assessments (U.S. Department of Health and Human Services [HHS], 2020). They should also implement internal audit systems and provider training to recognize and document preventable versus unavoidable ulcers.

The role of potential whistleblowers, or qui tam relators, is integral under the False Claims Act (FCA). Healthcare employees who suspect fraudulent claims—such as billing for preventable conditions that should not have been reimbursed—can report these abuses anonymously. The FCA incentivizes reporting through potential recoveries and penalties, compelling organizations to maintain ethical billing practices (U.S. Department of Justice, 2022). Thus, compliance programs that promote transparency and accountability are crucial for mitigating legal risks.

The CMS decision to reduce reimbursement for hospital-acquired pressure ulcers was grounded in the intent to improve patient safety and reduce unnecessary healthcare costs associated with preventable injuries. This policy aligns with broader public health goals, encouraging hospitals to invest in preventive strategies. Legally, CMS’s determination was based on evidence linking hospital practices to patient outcomes and the goal of reducing moral hazard—where providers might otherwise neglect prevention if reimbursements remain guaranteed for all outcomes (Centers for Medicare & Medicaid Services [CMS], 2008). Although analytically justified, critics argue that the policy can penalize hospitals serving higher-risk populations, potentially widening disparities.

Ethically, withholding reimbursement for certain hospital-acquired conditions raises questions about fairness and the potential for unintended consequences, such as hospitals avoiding high-risk patients or falsifying documentation to avoid penalties. Ethical concerns revolve around transparency, equitable care, and the obligation of institutions to prioritize patient safety over financial incentives (Mann & Meryn, 2020). Administrators can address these concerns by fostering a culture of safety, emphasizing accurate documentation, and implementing system-wide quality improvement initiatives. This includes integrating pressure ulcer prevention into staff training, utilizing electronic health records for risk assessment, and fostering interfacility communication to ensure continuity of care.

Regarding relationships with SNFs, hospital administrators should engage in collaborative efforts that promote best practices, joint training, and shared accountability for patient outcomes. Building trust and transparency with SNFs can help ensure that preventive measures are initiated early and that documentation accurately reflects patients’ clinical status at discharge. Policies that encourage transparent reporting and performance benchmarking can motivate SNFs to improve skin care practices, thereby reducing the incidence of pressure ulcers across settings.

In conclusion, the case exemplifies the intricate balance between regulatory compliance, ethical obligations, and the pursuit of high-quality patient care. Administrative strategies must include meticulous documentation, staff education, system-wide quality initiatives, and interfacility collaboration. Addressing these elements holistically not only aligns with legal and ethical standards but also enhances organizational reputation and patient safety.

References

• Centers for Medicare & Medicaid Services. (2008). Hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system, FY 2008. https://www.cms.gov
• Mann, G., & Meryn, S. (2020). Ethical considerations in patient safety and hospital reimbursement policies. Journal of Healthcare Ethics, 14(2), 123-135.
• Rafter, M., Ryan, D., & McGowan, B. (2014). Pressure ulcer prevention and management. British Journal of Nursing, 23(4), 218-221.
• U.S. Department of Health and Human Services. (2020). Pressure ulcers: Prevention & management. https://www.hhs.gov
• U.S. Department of Justice. (2022). The False Claims Act. https://www.justice.gov/civil/fca