Two leading federal agencies are warning hospitals and other facilities that they can be fined and denied Medicare funds if they are caught intentionally underreporting healthcare-associated infections (HAIs).

As CMS pay-for-performance penalties and incentives target infection control, there are “anecdotal reports” of hospitals attempting to skirt the rules and not report all HAIs to the CDC. An Oct. 7 CDC-CMS joint statement reminds all facilities that it is critical to report all HAIs to the CDC’s National Healthcare Safety Network (NHSN).

The gold standard surveillance system has expanded in recent years as CMS began linking infection rates to reimbursement. Many had predicted that pay-for-performance would inevitably lead to such a situation, as fiscally strapped hospitals may succumb to the temptation of underreporting. The strongly worded statement contained some warnings of consequences and allegations of unethical behavior, but a CDC official interviewed for this story took a more conciliatory tack.

“This is about due diligence,” says Michael Bell, MD, a medical epidemiologist in the CDC’s Division of Healthcare Quality Promotion. “We don’t have a sense of how common this is — we don’t know that it is happening very much but because the data are now used for reimbursement, we just wanted to put out a reminder that there is an added level of responsibility in terms of accuracy. You don’t want to fall into a situation of misrepresenting information that is related to payment. A lot of people who have traditionally looked at these data from an infection control perspective maybe aren’t thinking of it [that way].”

The joint statement said that the CDC “has received reports from NHSN users indicating that in some healthcare facilities, some of the decisions about what infections should be reported to NHSN are made by individuals who may choose to disregard CDC’s protocol, definitions, and criteria or who are not thoroughly familiar with the NHSN specifications. While there is no evidence of a widespread problem, CDC and CMS take any deviation from NHSN protocols seriously.”

In some cases, the decisions may be made through a review process that “overrules the decision of an infection preventionist or hospital epidemiologist” to report an infection to NHSN, the CDC and CMS reported. Other issues of concern are reports that some facilities are ordering diagnostic tests in the absence of clinical symptoms.

“It has been reported that in some instances, when patients are admitted to a hospital, diagnostic microbiology tests are ordered even in the absence of clinical indications for testing, such as obtaining urine specimens for culture and sensitivity testing from patients who have no symptoms of a urinary tract infection,” the agencies stated. “Many negative culture results are generated by this practice subjecting the patient to potentially unnecessary tests. On the occasion that a culture result is positive, the results are then used to assert that infections that first manifested themselves clinically many days later during hospitalization were present on admission and hence not reportable to NHSN.”

Again, there were clear warnings by IPs and other clinicians that these types of strategies may be adopted as CMS began declining full reimbursement for certain hospital-acquired conditions that could be perceived as preventable. However, few probably anticipated the most serious allegation: reports that some facilities are “discouraging the ordering of diagnostic tests in the presence of clinical symptoms. It has been reported that in some instances clinicians responsible for inpatient care in some hospitals may be discouraged from ordering diagnostic microbiology tests recommended by best medical practices (or standards of care) to avoid test results that would make infections reportable to NHSN,” the CDC and CMS reported.

Bell said he had no additional information on that allegation, but added that testing, in general, can be done inappropriately in an effort to secure reimbursement. The CDC’s NHSN has validation systems and CMS does “spot checks” of facilities reporting data linked to reimbursement, Bell adds. In addition, CMS warned of serious consequences and called for whistleblowers to call a tip line.

“CMS reminds hospitals that intentionally reporting incorrect data, or deliberately failing to report data that are required to be reported, may violate applicable Medicare laws and regulations,” the joint statement read. “The Department of Health and Human Services’ Office of Inspector General (OIG) protects the integrity of HHS programs, including Medicare and Medicaid. The Inspector General has the authority to exclude individuals and entities from participation in the Medicare, Medicaid, and other Federal healthcare programs and to impose Civil Monetary Penalties for certain misconduct related to Federal healthcare care programs. Hospital staff who become aware of intentional deviations from NHSN reporting protocols are encouraged to report their concerns to the OIG hotline.”

OIG reporting can be done via any of the following:

Phone: 1 (800)-HHS-TIPS

1 (800)-447-8477

Fax: 1 (800)-223-8164

Email: HHSTips@oig.hhs.gov

For questions about the content of the notice, contact: CDC Division of Healthcare Quality Promotion Policy Office

Phone: (404) 639-4000

Email: DHQP_Policy@cdc.gov