Aetna has established new, tighter policies dictating when it will and will not reimburse for medical care related to errors made by providers.
While last year the insurer established
nonpayment contract language regarding hospital errors , the new policies are considered payment policies, which fall under a different legal obligation and carry stronger protections for consumers, according to an Aetna spokeswoman.
Under the policies, Aetna has broken errors into two categories: “never events”—three events involving surgery: wrong patient, wrong site and wrong procedure—and 25 serious reportable events as defined by the National Quality Forum. Providers will not be reimbursed for a case involving one of the three never events, under the new payment policy. Of the 25 events, eight will be reviewed by Aetna to determine whether reimbursement should be withheld. The rest of the events will also be reviewed under Aetna's new policy, but they will not be considered eligible for adjustments to reimbursement, the spokeswoman said.
In addition to not paying for care related to those events, Aetna is requiring providers to report the errors to the Joint Commission, a state reporting agency, or a patient-safety organization as well as to the insurer under the new policies. Providers will work with Aetna medical directors to analyze the system when an error occurs, and providers will have to communicate with the patient and family members about the event as well.
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