The Centers for Medicare and Medicaid Services (CMS) have identified pressure ulcers, or bedsores, as one of the hospital-acquired conditions, or “never events,” that they will not reimburse at the normal rate under Medicare. Pressure ulcers develop over time. One challenge facing health care organizations is getting proper reimbursement for services in cases of patient transfer if the patient’s conditions were acquired elsewhere.

·         Read the following scenario:

A Medicare patient is admitted from a skilled nursing facility for dehydration. There is a close clinical relationship between the facilities, with admissions and services at both facilities referred to each other. A day or two after admission, a pressure ulcer is assessed. There is concern at the hospital about whether they will be paid for this condition.

The hospital staff claims that the pressure sore was caused by the local skilled nursing facility. The skilled nursing facility did not document any skin issues prior to discharge and believes the hospital is blaming it for the hospital’s poor skin care.

As an administrator in this hospital, you would naturally want to get reimbursed for the care now required to treat this patient’s pressure ulcer, to prevent this kind of issue from happening in the future, and also to maintain good organizational ties with this skilled nursing facility.

·         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.

·         From a legal standpoint, does the CMS policy regarding reduced reimbursement for hospital-acquired pressure ulcers and other conditions make sense to you? Why? Does the policy raise any ethical issues?

·         In what ways could systems be altered 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?

·         Conduct 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 the Learning Resources.