WellPoint Refuses to Pay for Medical Mistakes

WellPoint Inc. is changing its provider reimbursement strategy to withhold payment for certain medical errors.

The reimbursement modifications, which involve preventable adverse events as defined by the Centers for Medicare and Medicaid Services and the National Quality Forum, will be implemented in phases and be modified and expanded. Prior to this announcement, the policy had been implemented on a pilot basis in Virginia.

The Indianapolis-based health insurer will not pay for surgery performed on the wrong body part, for surgery on the wrong patient, or for the wrong surgery being performed on a patient. In addition, WellPoint will not make any additional payments if any of the following occur:

* Object left in the body during surgery.
* Air embolism or blockage.
* Blood incompatibility.
* Catheter-associated urinary tract infection.
* Pressure ulcers.
* Vascular catheter-associated infection.
* Infection inside the chest after coronary artery bypass graft surgery.
* Hospital-acquired injuries such as fractures, dislocations, intracranial injuries, crushing injuries and burns.

“WellPoint firmly believes that putting processes in place that focus on preventing these events can have an immediate impact on health care safety and quality,” Dr. Sam Nussbaum, executive vice president for clinical health policy and WellPoint’s chief medical officer, said in a statement.

“We will continue to work collaboratively with physicians and hospitals to analyze why and how these events occur, and to proactively find ways to improve patient safety and clinical care,” he said.

The new strategy also will save patients and employers money since it does not permit in-network hospitals to bill them for such errors, according to WellPoint.

WellPoint joins a growing list of payers that are no longer reimbursing providers for health care costs stemming from preventable medical errors. Earlier this year, Aetna Inc. said it had begun to include provisions in some provider contracts that they won’t pay for nor allow patients to be billed for care related to the so-called “never events” identified by the National Quality Forum.

Last August, CMS announced it would no longer pay for some hospital mistakes beginning on October 1, 2008. In addition, the Washington-based Leapfrog Group, a consortium of large, national employers focused on patient safety, has announced its support of such payment denials.

In 2002, the National Quality Forum defined 27 events that should never occur within a health care facility.

There are six types of so-called “never events”: surgical errors; product or device events, such as using contaminated drugs; patient protection events, such as discharging an infant to the wrong person; care management events, such as medication errors; environmental events, such as electric shocks or burns; and criminal events, such as the sexual assault of a patient.

Filed by Joanne Wojcik of Business Insurance, a sister publication of Workforce Management. To comment, e-mail editors@workforce.com.