Critical Path Network

Insurer refuses to pay for wrong-site/person surgery

The movement to prevent wrong-site or wrong-person surgery got another boost recently when a major health plan announced affective Jan. 1, 2005, it will no longer pay for medical procedures involving those egregious errors.

Don’t expect to get paid for a procedure if you leave that 12-inch retractor in the patient’s belly, or the next procedure to remove it.

HealthPartners, one of Minnesota’s biggest health plans, announced recently it would not pay for procedures involving never events — those mistakes so serious and preventable that they should be eliminated entirely, not just reduced.

George Isham, MD, medical director for HealthPartners, says, "We all agree that patients should not pay for medical care made necessary by one of these errors. This is especially important as consumers are asked to bear more of the costs of their care premiums, deductibles, and copayments."

Noting that some hospitals already waive the costs associated with these errors, he says HealthPartners wants to "work with hospitals, physicians, nurses, and others to make sure this is the case for every patient, every time."

Isham notes that the new HealthPartners philosophy extends to all serious, preventable adverse events. Wrong-site surgery is just the most obvious example, he says.

HealthPartners provides health coverage to 630,000 members and has a network of physicians and hospitals, including HealthPartners Clinics. It is the state’s third biggest health insurer, after Blue Cross and Blue Shield of Minnesota and Medica.

Providers in Minnesota have been required to report adverse events since July 2003. Isham says there have been 40 adverse events in the first 10 months of reporting from 15 hospitals that contract with HealthPartners. Of those 40, 14 involved care management and 18 to surgical procedures. The surgical events involved 10 incidences of surgery on the wrong site or wrong patient, or the wrong surgical procedure.

The new policy will require any hospital contracting with HealthPartners to report serious adverse events within 10 days, giving the insurer time to identify the procedures it will not pay for before the end of the billing cycle.