Dec. 9, 2021

Our Medicare Advantage plans provide Part A (hospital) and Part B (medical) coverage for services as original Medicare plans, while generally including additional services such as wellness programs and more. 

As part of Centers for Medicare & Medicaid Services’ (CMS) Hospital Readmissions Reduction Program (HRRP), which began Oct. 1, 2012, hospitals that participate with the Medicare Advantage network are encouraged to improve communication and care coordination to better engage patients and caregivers in discharge plans.  This, in turn, helps to reduce avoidable readmissions.

CMS includes the following conditions or procedure-specific 30-day risk-standardized unplanning readmission measures in the program:

• Acute myocardial infarction (AMI)
• Chronic obstructive pulmonary disease (COPD)
• Heart failure (HF)
• Pneumonia
• Coronary artery bypass graft (CABG) surgery
• Elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA)

What this means to you:

Hospitals that have submitted claims with dates of service that include a readmission occurring in less than 30 days for the same or similar diagnosis as a prior discharge will be required to submit clinical records for review.  The records will be reviewed for evidence of incomplete care, missed diagnosis, or incomplete discharge planning.

• Incomplete care is defined as discharge prior to complete treatment of a patient’s condition.
• Missed diagnosis is defined as discharge with a known, but untreated or under treated condition.
• Incomplete discharge planning is defined as discharge without ensure that medications are obtained, follow up appointments are made, and/or home health care started.

Below are the circumstances in which a readmission will be deemed inappropriate or preventable:

• If the readmission was medically unnecessary;
• If the readmission resulted from a prior premature discharge from the same hospital or a related hospital;
• If the readmission resulted from a failure to have proper and adequate discharge planning;
• If the readmission resulted from a failure to have proper coordination between the inpatient and outpatient health care teams; and/or
• If the readmission was the result of circumvention of the contracted rate by the hospital or a related hospital.

If a request for clinical records is received, the documentation must be submitted within 30 days or it will be assumed that the hospital agrees that the readmission was preventable and full remittance of the paid amount will be expected.  Once records are received, the hospital will be notified in writing within seven days if the records show the readmission was preventable based on the above-mentioned reasons.

If the hospital agrees that the readmission was preventable, they may respond with remittance of the paid amount for the admission.  If they disagree with the initial review, they may respond by providing additional clinical documentation supporting complete care, no insufficiently treated conditions, and complete discharge planning.

Once the additional documentation is received, they will be notified in writing within seven days of the determination.  Upon the completion of the second review, if the readmission is still deemed preventable, the remittance of the paid amount for the preventable admission will be expected.

Exclusions

The following readmissions are excluded from 30-day readmission review:

• Transfers from out-of-network to in-network facilities;

• Transfer of patients to receive care not available at the first facility;
• Readmissions that are planned for repetitive or staged treatments, such as cancer chemotherapy or staged surgical procedures;
• Readmissions associated with malignancies, burns, or cystic fibrosis;
• Admissions to skilled nursing facilities (SNF), long term acute care facilities (LTAC), and inpatient rehabilitation facilities (IRF)
• Readmissions where the first admission had a discharge status of “left against medical advice”;
• Obstetrical readmissions;
• Readmissions greater than or equal to 31 days from the data of discharge from the first admission.

If you have any questions regarding this bulletin, please contact Provider Education using the Provider Education Contact Form located on www.SouthCarolinaBlues.com.