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Frequently Asked Questions - Medicaid Serious Adverse Event Reimbursement

Questions

Event Definitions

IPRO Review Process

Medicaid Managed Care

Follow-up Care

Physicians

Dual Eligibles

Rate Codes and Billing Process

Answers

What is the definition of a Serious Adverse Event (SAE) under the New York State Medicaid inpatient payment policy?

A SAE is defined by the Department of Health (DOH) as "avoidable hospital complications and medical errors that are identifiable, preventable, serious in their consequences to patient, and increase costs to the Medicaid program."

What is the definition of "disability associated with?"

Any injury or impairment which may result in the need for increased care, or changes in care/services required by a patient that is associated with increased costs to the Medicaid program. If an injury or impairment does not result in increased costs to the Medicaid program, it is not included under the definition of disability.

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Does the definition of burns include those burns that are self-incurred?

No

What types of events are contemplated by the " of restraints or bedrails" and how does this apply to an inpatient mental health unit?

Any injury related to the use of restraints or bedrails that may result in need for additional care or services that results in increased costs to the Medicaid program. This policy applies to any inpatient care, including care provided in an inpatient mental health unit.

What types of medication errors are included in the Medicaid SAE policy?

Any medication related SAE that is associated with increased costs to the Medicaid program may be included in this policy. This includes medication related SAEs resulting in the need for treatment, intervention, initial or prolonged hospitalization, patient harm resulting in transfer to a higher level of care, any cardiac/respiratory arrest, death (including those not the direct result of a medication error), and known drug-drug interaction. The policy excludes adverse drug reactions that are not the result of a medication error.

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Why in some cases are the event definitions aligned with NYPORTS and other cases the definition is expanded for purposes of the adverse event policy? Why doesn't DOH use the NYPORTS definition of disability?

The New York State DOH Serious Adverse Event Policy is applicable to SAEs that lead to increased costs to the Medicaid program. NYPORTS definitions do not take costs into consideration. In some cases an adverse event may result in increased costs to the Medicaid program, but is not reportable under NYPORTS.

What is the purpose of the IPRO review if rate code 2590 (non-reimbursable with SAE) is assigned by the hospital on the claim?

IPRO will conduct payment and quality reviews for all SAEs subject to this Medicaid payment policy.

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How will IPRO request information from the hospital regarding the SAE and what time frames will DOH and IPRO adopt in their own review process?

IPRO will send a chart request letter to the hospital once DOH notifies them about the SAE and need for review. Included with the letter will be a "checklist" that will be used by the hospital to identify the SAE and the date on which the SAE is believed to have occurred. This will assist IPRO in focusing their chart review on the specific SAE identified. The provider will have 30 days to submit the requested information. The IPRO review should be complete within 30-45 days of chart receipt. Following review, IPRO will send a preliminary notification of findings to the hospital. The hospital has 30 days to respond in disagreement with additional documentation and/or justification. If the hospital does not respond within that time period, IPRO will finalize its findings. IPRO will send written notification of the final determination to both DOH and the hospital. DOH will then process the payment adjustments accordingly.

Is there an appeals process?

The provider will have one opportunity to appeal determinations made by IPRO. However, if the provider does not respond to the initial request for the chart timely (within 30 days) and a technical denial is issued, the request for re-opening of the claim is considered the provider's appeal of the case and no appeal of IPRO's determination will be permitted.

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Will Medicaid managed care plans be required to adopt the DOH policy?

Effective January 1, 2010, Medicaid managed care plans are required to adopt an approach that is consistent with the DOH payment policy for SAEs. This includes using the same list of SAEs, however, the mechanism for identifying the SAE may differ from the Medicaid fee-for-service program.

Generally, rate codes are not used to bill Medicaid managed care plans. How should SAEs for Medicaid managed care enrollees be identified and billed?

Medicaid managed care plans are required to establish their own mechanism to identify and review SAEs. They may choose to allow their billing systems to accept rate codes, or they may develop another system - either prospective or retrospective.

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If an SAE occurs for an enrollee in a Medicaid managed care plan, how will the GME billing (rate code 3130) to DOH be handled?

The hospital is encouraged to bill a GME claim using rate code 3130 for all qualifying admissions.

If the patient is admitted to a hospital due to an SAE that occurred at another institution, or outpatient setting, will the second hospital be allowed to bill for the full readmission? What rate code should be used?

Currently the second hospital would be able to bill and receive full payment for the (re)admission because the SAE did not occur at this second hospital. For all discharges occurring after April 1st 2010, the second hospital should bill using the appropriate DRG (or per diem) and then adjust the claim using SAE rate code 2591 (DRG) or 2592 (per diem). The second hospital will receive timely and full payment but the claim will be flagged for IPRO to enable the Department to track these events. Outpatient care is not impacted by this policy.

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If the patient is subsequently admitted to the same hospital due solely to an SAE, but is seen by a different physician, would the hospital receive payment for this subsequent admission?

Subsequent admissions to the same hospital due solely to an SAE that occurred at that institution would not receive full payment, and therefore the subsequent admission should be billed using the SAE rate code 2590 (non-reimbursable SAE). Physician payments are not affected by this policy.

If the patient is subsequently admitted to the same hospital for care and treatment not solely related to an SAE, but is seen by a different physician, would the hospital receive payment for this subsequent admission?

Subsequent admissions to the same hospital for care and treatment not solely related to an SAE that occurred at that institution are eligible for partial payment, and therefore the subsequent admission should be billed using the appropriate SAE rate code, either 2591 DRG with SAE) or 2592 (Per diem with SAE). Physician payments are not affected by this policy.

Is there a time limit associated with the reduced/no-payment policy for subsequent admissions to the same hospital where the SAE occurred and does it start at the discharge date or the date of the actual incident?

Any subsequent hospital admission required to treat a patient as a result of a SAE that occurred at that same hospital on a prior admission will be subject to review and possible payment reduction regardless of the time period between admissions. Hospitals can submit adjusted claims up to six years after the initial submission. If a SAE is uncovered within that time period, an adjusted claim with the appropriate rate code should be submitted as soon as possible after the event is discovered.

Are physicians, whether they are employed by the hospital or members of the voluntary staff included under this policy?

Physician payment is not impacted by this policy, at this time.

If a physician performs a surgery on the wrong body part, can that physician bill Medicaid for the surgery?

Yes, physician payment is not impacted by this policy at this time.

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What implications are there, if any, for patients with dual insurance, i.e., Medicare and Medicaid?

None.

What is meant by Per Diem in new rate code 2592?

This refers to exempt units that are reimbursed by Medicaid on a per diem basis. For those claims subject to the Medicaid DRG reimbursement methodology with an associated SAE, 2591 is the rate code to be used.

What should a provider do if a SAE is discovered several weeks or months after the claim for the admission has been submitted and paid?

Hospitals can submit adjustment claims up to six years after the initial submission so if a SAE is uncovered within that time period, an adjusted claim with the appropriate SAE rate code should be submitted as soon as possible after the event is discovered.

Are denied days counted towards the Medicaid Disproportionate Share Hospital (DSH) cap?

No, denied days will not be counted towards the hospital's Medicaid DSH cap.

How are "costs" defined? Are costs defined as costs to the Medicaid program or costs related to the treatment of the patient?

"Costs" are defined as reimbursement provided by Medicaid.

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How would the partial payment be determined in the case of flat rate provider?

Partial payments to flat rate hospitals will be calculated the same way partial payments will be calculated for all other hospitals. In cases where a partial payment is determined to be appropriate, IPRO will review the chart and may eliminate ICD-9-CM codes, which could affect the cases APR-DRG assignment or reduce allowed charges, which may affect the receipt of an outlier payment.

Generally, how will this policy affect the calculation of inpatient reform rates and cost reporting?

The Medicaid SAE policy will have no affect on the calculation of inpatient rates or cost reporting. The costs incurred and days/discharges of services provided by the hospital should be reported in the Institutional Cost Report.

Is there any implication for the annual institutional cost report?

No, the days, discharges, and costs should be reported as usual. It is only the Medicaid payments that are potentially affected by the policy.

What information is subject to the State's Freedom of Information Law (FOIL)? Will outside entities be able to "FOIL" the rate codes or other related information that a SAE occurred at a specific hospital?

Information obtained by the Department in implementing a payment adjustment is subject to the Freedom of Information Law. Private patient information is not releasable unless an authorized party is providing the Department with a legal release. Any Public Health Law Section 2805-m materials pertaining to Quality Assurance or Incident Reporting as submitted by the facility is exempt from release. However, records that separately detail quality assurance or incident reporting matter by Department staff are not exempt.

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When a provider identifies a case that meets the definition of an SAE and it also meets a NYPORTS definition, does a report still have to be made to the NYPORTS system?

Yes. NYPORTS reporting requirements are part of the New York State Code of Rules and Regulations (NYCRR) Part 405.8, and are separate and apart from reporting requirements under this Medicaid payment policy for SAEs.