Application: Medicare and a Never-Event Involving a Patient Transfer Case
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 administrators and providers is getting proper reimbursement for their services in cases of patient transfer if the patient’s conditions were acquired elsewhere.
For this Application you will analyze the legal, financial, and ethical considerations of a case involving patient transfer, based on 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.
To prepare for this Application Assignment, complete the following:
The Application Assignment:
With these thoughts in mind, write a 3- to 4-page paper in which you address the following questions:
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 weeks’ 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.
This chapter describes the role of the U.S. Office of Government Ethics in relation to health care, and outlines key laws involving admission (e.g., EMTALA), antitrust, and other laws associated with interagency relationships or obligations related to government funding.
Criminal law is described in Chapter 5, including sections outlining patient abuse, false claims, kickbacks, and fraud. Health care organizations are required by law to document and report a variety of measures, generally in connection with public health and safety. Chapter 17 describes these and also explains corporate compliance programs.
Legal aspects of managed care organizations (MCOs), mergers, and the restructuring of more traditional health care organizations are discussed in Chapter 19. Also included is an explanation of price-fixing, which is a violation of antitrust laws.
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