Pressure ulcers disease - Case Study Example

MEDICARE AND A NEVER EVENT INVOLVING A PATIENT TRANSFER CASE Factors for receiving pressure ulcers proper skin care Technically, patients who spend more time on the bed as patients with reduced mobility have higher risks of suffering from pressure ulcers (Stanton, 2001). As the disease is identified to be very painful, and in some cases it is difficult to treat, it is extremely important that the approach taken to treat pressure ulcers include prevention, early detection, and intensive and proper skin care. The patients at risk must receive proper skin care if the occurrence of pressure ulcers is to be curtailed. The following kinds of patients are at risk of having pressure ulcers: patients who spend long days on their sickbed without moving (for reason of sensory loss, they do not have sensations of their skin); patients who have expressed wider indications of changes in mental stability; patients who begin to lose weight as a result of poor nutrition; and patients who have fragile and thin skin as a result of aging (Morrow, 2009). As soon as a patient fits any of these descriptions, it is important that certain critical care factors be offered. These are some of the care factors: rapid response to relieve the potential spot of pressure; constant application of dressing to clean the sore; undertaking expert-based risk assessment; and application of urgent wound-management techniques (Bennett & Medearis, 2003). Each of these factors ought to be carried out with urgency and by use of the appropriate clinical practices to ensure that immediate interventions and remedies are assigned. Dealing with false claims The Never Event Policy was generally instituted to ensure that hospitals and health care facilities give the very best of care to patients so that patients would not have to come out of hospitals and health facilities with new illnesses. It is for this reason that some key hospital-related conditions have been set apart under the Never Event Policy with the aim that these conditions do not happen at the health facilities. Some of these key conditions are “wrong-site surgeries, transfusion with the wrong blood type, pressure ulcers, falls or trauma, and nosocomial infections” (Torrey, 2011). There, however, remain some key components of the Never Event Policy that hospital administrators must be concerned about. One of these is false claims associated with the report of never event conditions (Morris, 2003). False claims take place in two major ways, and each of these can be curtailed by the hospital administration. The first has to do with cases of the patient transfer, when the latter hospital is making claims of never event conditions in the patient being transferred against the former hospital. There could also be a case when a patient makes claims of never event conditions. Because never event conditions are not covered under Medicare, any claims of their existence lead to payments to be made by the accused hospital. Administrators can, on the other hand, take steps to ensure that for services for which payment is not available under applicable rules, false claims are not taken. Part of the intervention could be the setting up of a quality control department that would be charged with the task of ensuring that all claims are thoroughly researched, scrutinized, and, consequently, covered. Again, the department should be tasked to ensure that the hospital does not commit genuine mistakes that the hospital could be charged for false claims. Activities that protect whistle blowers should also be strengthened to ensure that there is always trust among the general public and employees to report acts of false claims (McKessy & Robert, 2008). Some of these conditions to ensure protection could include the need to submit suspicions anonymously and confidentially. CMS policy regarding reduced reimbursement From a legal standpoint, one may argue the need to protect the interests of the patient as the patient visits a health facility. As far as this perspective of the debate is concerned, it should be said that the policy regarding reduced reimbursement for hospital-acquired pressure ulcers makes a lot of sense. After all, hospital-acquired pressure ulcers are preventable and the health professionals should be in a position to undertake preventive tasks (Kalb, 1998). In the process of critical care, the professionals should be able to learn if a particular patient is at risk of contracting pressure ulcers and, consequently, needs to be given extra care. Ethically, health facilities are more challenged to live up to their responsibilities by ensuring that patients receive maximum care once at the facility. These points notwithstanding, it can clearly be seen that the reimbursement for hospital-acquired pressure ulcers would put much pressure on hospitals to intensify care more than they would naturally have done (Grayson, 2008). From this perspective, hospitals should have a legal basis to ask for increased payment for general care, which would cover the extra care to be given to patients to avoid incidents of hospital-acquired pressure ulcers. Dealing with skilled nursing facility The need to maintain high standards in healthcare practice should continue to remain an important priority for all healthcare facilities. The standardization in relation to the kind of facility involved should not be respected. This means that even though smaller facilities like clinics, maternity homes and skilled nursing facilities may not be in a position to deliver the kind of services given in hospitals, this should not be a basis for them to deliver poor and sub-standard services (Friedman, 2006). In the event of the scenario given, the hospital administrator can ensure that the system is not impacted by gargantuan payments due to such negligent practices; he or she can do this by acting as an informer, so that this nursing facility’s standard practices are critically checked. Even though the need for the mutual respect and cordiality between the hospital and the skilled nursing facility ought to remain of high priority, it is equally important that patients are protected and that adverse conditions do not result in the plague of payments (Sparrow, 2006). There could, therefore, be a system that ensures that patients coming from the identified skilled nursing facility are always given special scrutiny upon arrival (for non-emergency cases) to ensure that the hospital will not be paying for any claims of adverse conditions that do not emanate from the hospital. References Bennett R. S., & Medearis, D.M. (2003). Health care fraud: Recent developments and timeless advice. Texas Medicine, 99(10), 50-56. Friedman, M. (2006). Health care fraud: Your risk may be greater than you think. Maryland Medical Journal, 45, 825-826. Grayson, M. (2008). License to steal: Combating health care fraud. Spectrum: Journal of State Government, 71, 1-3. Kalb, P. E. (1999). Health care fraud and abuse. Journal of American Medical Association, 282(12), 1163-1168. McKessy, Ana-Maria, & Robert J. Saner II (2008). Protecting your practice with a Medicare and Medicaid Compliance Program. Family Practice Management, 5(7), 57-66. Morris, L. (2003). Health care fraud: a primer on the schemes and the tools to fight health care fraud. Journal of Insurance Medicine, 25, 415-419. Morrow A. (2009) Pressure ulcers: Knowing the risks. Retrieved from http://dying.about.com/od/caregiving/a/pressure_ulcer.htm Sparrow, M. K. (2006). Health care fraud control: Understanding the challenge. Journal of Insurance Medicine, 28(2), 86-96. Stanton, T. H. (2001). Fraud-and-abuse enforcement in Medicare: Finding middle ground. Health Affairs, 20(4), 28-41. Torrey T. (2011). Learn about Medicare's Never Events Policy. Retrieved from http://patients.about.com/od/patientempowermentissues/a/medicare08never.htm Read More