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Important Announcement Regarding Preventable Serious Adverse Events and Never Events
Gateway Health Plan® (Gateway) is committed to providing quality health care services to its members; therefore as required by The Centers for Medicare and Medicaid Services (CMS), the Pennsylvania Department of Public Welfare (DPW), and all other applicable state and federal regulators, Gateway has established a policy to address identification and payment related to Preventable Serious Adverse Events, Hospital Acquired Conditions, and Never Events.
As a reminder: Inpatient Prospective Payment System (IPPS) hospitals (except those EXEMPT from POA) are required to submit present on admission (POA) information on diagnoses for inpatient discharges.
Definitions:
Preventable Serious Adverse Event (PSAE):
A clearly defined occurrence that could have been anticipated and prepared for, but occurs because of an error or other system failure that results in death or loss of a body part, disability or loss of bodily function lasting more than seven days or still present at the time of discharge from an inpatient acute care general hospital.
Hospital Acquired Conditions (HAC):
Conditions those are reasonably preventable by following evidence-based guidelines that are either costly or common. HAC provisions apply only to inpatient hospital stays.
Never Event:
An adverse event that is serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability. They are events that should never occur. Never Events apply to an Inpatient, Outpatient, Special Procedure Unit (SPU) and Ambulatory Surgical Centers (ASC) settings, practitioners and other bills.
Procedure:
Potential PSAE/HAC and Never Events are identified by several internal and external mechanisms such as, but not limited to, claims payment retrospective review, utilization management case review, complaint and grievance review, fraud and abuse investigations, practitioner/providers, delegates, and state and/or federal agencies. Once a potential event has been identified an extensive review is conducted by the Quality Improvement and Medical Management Departments at Gateway. The process includes a medical record review and possible telephonic or mail communication with the practitioner/provider. Upon final determination if an actual event has been discovered, Gateway will notify the practitioner/provider by mail that payment denial or retraction will occur.
Should you have any questions, please contact your Provider Relations Representative or you may also contact Gateway’s Provider Services Department at 1-800-392-1145. Thank you for your continued support of Gateway Health Plan® and our mission.
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