What’s a Never Event?
The more appropriate term for a Never Event, is Serious Reportable Event (SRE). This term was first coined in 2002 by the National Quality Forum (NQF).[1] According to the NQF, “Preventing adverse events in healthcare is central to NQF’s patient safety efforts. To ensure that all patients are protected from injury while receiving care, NQF has developed and endorsed a set ofSerious Reportable Events (SREs). This set is a compilation of serious, largely preventable, and harmful clinical events, designed to help the healthcare field assess, measure, and report performance in providing safe care.”
The original list of 27 SREs has grown to 29 and they are broken down into the following categories:
- SURGICAL OR INVASIVE PROCEDURE EVENTS
- PRODUCT OR DEVICE EVENTS
- PATIENT PROTECTION EVENTS
- CARE MANAGEMENT EVENTS
- ENVIRONMENTAL EVENTS
- RADIOLOGIC EVENTS
- POTENTIAL CRIMINAL EVENTS
Why is this important?
Special Investigation Units (SIU) are usually tasked with just combating Fraud, Waste and Abuse (FWA). Often SIUs receive referrals from a variety of business units throughout payer organizations in an attempt to discern if there is FWA and/or quality of care issues as well. In addition, SREs may be the result of services that were never rendered or billed improperly.
What do I look for?
There are several ways to mine the data to detect possible SREs. For example, Modifier PA on a claim indicates “Surgical or otherwise invasive procedure on the wrong body part.”[2] Medicare does not reimburse “when the practitioner erroneously performs: 1) a different procedure altogether; 2) the correct procedure but on the wrong body part; or 3) the correct procedure but on the wrong patient.”
Does your plan cover these services? If so, how much has your organization paid for these services and how often is this occurring? Just some of the other codes to look for include:
1) Modifier PB -Surgical or otherwise invasive procedure on the wrong patient[3]
2) Modifier PC-Wrong surgery or other invasive procedure on patient[4]
3) Various diagnosis codes indicating the surgery was performed on the wrong body part: E870.9, E876.8
4) Various diagnosis codes indicating the surgery was performed on the wrong patient: E870.8, E870.9, E876.5, E876.8
Data mine on the examples above and review your plan’s policies to determine if these services are covered, and/or shouldn’t be covered.
If you have any questions, you may email our Subject Matter Experts at SIU@hcfraudshield.com.
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