Never Events and Serious Reportable Events
As part of Aetna's commitment to patient safety and quality, Aetna will not pay facility charges for "Never Events" and
some charges for "Serious Reportable Events" as described below.
The facility is required to notify Aetna of any Never Events, and Serious Reportable Events that occur in the provision of care to Aetna Members. The facility will waive all charges related to the Never Event or charges directly and solely related to the Serious Reportable Event. The facility will submit the bill identifying the event to Aetna but cannot charge the member or Aetna for the directly and solely related care and services provided. If Aetna learns of a potential Never Event or Serious Reportable Event – Reimbursement Review by a source other than the hospital, Aetna will notify the hospital and this policy will apply. Furthermore, if the claim has been reimbursed, we maintain the right to seek recovery of the overpaid charges as applicable.
****For purposes of this policy, Aetna has adopted the definitions and their revisions of Serious Reportable Events established by the National Quality Forum.
The National Quality Forum defines a "Never Event" as "errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility." For purposes of this policy, Aetna has determined the following events to be "Never Events:"
- Surgical or invasive procedure performed on the wrong person,
- Surgical or invasive procedure performed on the wrong side or body part, or
- The wrong surgical or invasive service is rendered.
Serious Reportable Events
In addition to the three Never Event situations, the National Quality Forum (NQF) has released a list of twenty- five Serious Reportable Events. These are considered by NQF to be potentially avoidable conditions "which could reasonably have been prevented through application of evidence based guidelines". These conditions are not present when patients are admitted to a facility, but occur during the course of the stay.
For the following Serious Reportable Events, the facility should submit claims to Aetna, but the facility should waive all costs directly and solely related to these events. Aetna will not pay for charges directly and solely related to these Serious Reportable Events, including an extended length of stay due to the event.
- Unintended retention of foreign object in a patient after surgery or other procedure
- Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA incompatible blood or blood products
- Patient death or serious disability associated with an electric shock while being cared for in a healthcare facility. Excludes events involving planned treatments such as electric countershock /elective cardioversion
- Intraoperative or immediately post-operative death in an ASA Class I patient
- Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by healthcare facility
- Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
- Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
- Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
The facility should submit claims for the following NQF Serious Reportable Events. Under the scope of this policy, reimbursement is not affected for the following conditions:
- Artificial insemination with the wrong donor sperm or donor egg
- Patient death or serious disability associated with patient elopement (disappearance)
- Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)
- Patient death or serious disability associated with a fall while being cared for in a healthcare facility
- Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended
- Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
- Infant discharge to wrong person
- Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
- Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility
- Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
- Stage 3 or 4 pressure ulcers acquired after admission to healthcare facility
- Patient death or serious disability due to spinal manipulative therapy
- Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
- Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
- Abduction of a patient of any age
- Sexual assault on a patient within or on the grounds of the healthcare facility
- Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility
Following the Leapfrog Group/NQF policy regarding Never Events and Serious Reportable Events, Aetna requires facilities to:
- In addition to notifying Aetna, the facility shall notify at least one of the following agencies within ten (10) days of
becoming aware that a Never Event or Serious Reportable Event has occurred:
- JCAHO, consistent with JCAHO's Sentinel Event policy; or
- State reporting program for medical errors; or,
- Patient Safety Organization (e.g. state-specific patient safety center).
- In accordance with the reporting agency's recommendations and health care facilities standards, a facility representative will perform a root cause analysis identifying the basic or causal factors that underlay the Never Event or Serious Reportable Event and identify changes that result in improvements to the facility's patient care systems and processes.
- A facility representative will communicate with the affected member and/or Member's family concerning the Never Event or Serious Reportable Event.
The reimbursement component of this policy is separate and distinct from other contracting policies regarding Present on Admission (POA) and Hospital Acquired Conditions (HAC).
web page updated: 08/15/2009