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Report File
Date Issued
Submitting OIG
Department of Health & Human Services OIG
Other Participating OIGs
Department of Health & Human Services OIG
Agencies Reviewed/Investigated
Department of Health & Human Services
Report Number
A-09-18-02004
Report Description

Provider-preventable conditions (PPCs) are certain reasonably preventable conditions caused by medical accidents or errors in a healthcare setting. In 2011, the Centers for Medicare & Medicaid Services (CMS) issued Federal regulations prohibiting Federal Medicaid payments for services related to PPCs. The goal of the regulations is to improve quality of care by prohibiting payments for medical errors. Prior OIG audits of nine States found that none of them fully complied with Federal requirements. Based on the information we compiled during those audits, we conducted this audit to identify actions that CMS could take to help States' compliance and to augment States' efforts to improve the quality of care provided to Medicaid beneficiaries.

Report Type
Audit
Agency Wide
Yes
Number of Recommendations
9
Questioned Costs
$0
Funds for Better Use
$0
Additional Details
https://oig.hhs.gov/oas/reports/region9/91802004.asp

Open Recommendations

This report has 7 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
268409 No $0 $0

We recommend that CMS issue clarifying guidance to States to help ensure that they use all of the diagnosis codes that inpatient hospitals report to them to identify PPCs.

268411 No $0 $0

We recommend that CMS work with States to ensure that their systems and processes for identifying PPCs use all diagnosis codes reported by inpatient hospitals.

268404 No $0 $0

We recommend that CMS issue a revised State plan preprint that contains all of the provisions identified in Federal requirements, if CMS continues to require States to use the preprint.

268406 No $0 $0

We recommend that CMS issue clarifying guidance to States to help ensure that they correctly use the Medicare HAC list to identify PPCs.

268407 No $0 $0

We recommend that CMS issue clarifying guidance to States to help ensure that they acquire from all inpatient hospital providers the information necessary to determine whether Medicare crossover claims contain PPCs and fully understand how to determine whether a crossover claim containing a PPC requires a payment adjustment.

268405 No $0 $0

We recommend that CMS issue clarifying guidance to States to help ensure that they identify PPCs on inpatient claims from all inpatient hospitals.

268408 No $0 $0

We recommend that CMS issue clarifying guidance to States to help ensure that they understand how and when to apply the “reasonably isolate” language in 42 CFR § 447.26(c)(3)(ii) as it relates to the limitation of reduction in payment for PPCs.

Department of Health & Human Services OIG

United States