Provider-preventable conditions face cuts

Document all conditions on admission

Now that the Centers for Medicare and Medicaid Services (CMS) has launched a program that adjusts Medicaid payments for provider-preventable conditions, including healthcare-acquired conditions, it's essential for case managers to work with physicians to make sure all conditions that are present on admission are clearly documented on a patient's chart.

CMS issued its final rule for the program on June 1 and gave state Medicaid programs until July 1, 2012, to implement a program to reduce payments to doctors, hospitals, and other healthcare providers for preventable conditions that otherwise would result in an increase in payment.

The final rule prohibits states from making payments to providers under the Medicaid program for conditions that are reasonably preventable. It uses Medicare's list of preventable conditions as a base and provides the states the flexibility to identify additional preventable conditions.

The final rule means that case managers should be scrutinizing the charts of Medicaid beneficiaries as closely as they do the charts of Medicare patients, says Deborah Hale, CCS, president of Administrative Consultant Services, a healthcare consulting firm based in Shawnee, OK. Hale recommends that case managers develop performance improvement initiatives that ensure that patients' records have complete and accurate documentation that distinguishes between the conditions that were present on admission and those that developed during the course of the hospital stay.

Work with the physicians who assess patients on admission, and be sure their documentation reflects any condition that is present on admission. Pay particularly close attention to patients who are transferred from other facilities, Hale advises. "This new rule is part of CMS' emphasis on value-based purchasing and pay-for-performance," she says. "Commercial payers are likely to follow suit." (To access the final rule for Medicaid provider-preventable conditions, visit


For more information contact:

  • Deborah Hale, CSS, President of Administrative Consultant Services, Shawnee, OK. E-mail: