Medicare Advantage Readmission

Administrative Policy:
Medicare Advantage Readmission

Effective Date:
February 15, 2017

Purpose:

  1. Readmissions to acute care hospitals occurring less than 31 calendar days from date of discharge are considered a quality of care issue and readmissions will be reviewed as such
  2. Horizon will review a Readmission hospitalization to determine: (1) that it was medically necessary, (2) that it was not a result of premature discharge of the patient from the same hospital, (3) that it did not result due to a lack of coordination in the transition of care between the acute care facility and the outpatient setting, or (4) if the care rendered on readmission could have been provided during the first initial admission
  3. Horizon created this policy to align itself with CMS’ Quality Improvement Organization (QIO) program

Definitions:

  1. Acute care facility is acute, general, short-term hospital
  2. Index hospitalization is the initial hospitalization at an acute care facility (hospital) where the discharge date occurred less than 31 days prior to the admission of the Readmission hospitalization
  3. Readmission hospitalization is a hospitalization at an acute care facility (hospital) whose admission occurred less than 31 days after the index hospitalization’s discharge date
  4. Same or similar condition or diagnoses is a condition or diagnosis which is the same or similar when compared between the Index hospitalization and Readmission hospitalization.
  5. Same, similar or related reason is where the reason for readmission is for the same, similar or related condition as the Index hospitalization.
  6. Same day is midnight to midnight of a single day.
  7. NOA is a Notice of Admission.
  8. Premature Discharge of Patient That Results in Subsequent Readmission of Patient to Same Hospital occurs when a patient is discharged even though he/she should have remained in the acute care facility for further testing or treatment or was not medically stable at the time of discharge. A patient is not medically stable when, in Horizon’s judgment, the patient's condition is such that it is medically unsound to discharge or transfer the patient. Evidence such as elevated temperature, postoperative wound draining or bleeding, or abnormal laboratory studies on the day of discharge indicate that a patient may have been prematurely discharged from the acute care facility.
  9. Readmission of Patient to Hospital for Care That Could Have Been Provided During First Admission This prohibited action occurs when a patient is readmitted to an acute care facility for care that, pursuant to professionally recognized standards of health care, could have been provided during the first admission. This action does not include circumstances in which it is not medically appropriate to provide the care during the first admission.
  10. Prospective/concurrent Review (CCR) is a request for coverage of medical care or services made while a member is in the process of receiving the requested medical care or services.
  11. Retrospective Review is a request for coverage of medical care or services after a member has received the requested medical care or services.

Scope:

This policy will be reviewed annually, revising procedures as necessary to reflect changes to specific guidelines.

This policy applies to Horizon Healthcare of New Jersey, Inc., Horizon Healthcare Services, Inc. and Horizon Insurance Company (collectively “Horizon”) across the following Government Programs lines of business:

  • Medicare Advantage Dual Special Needs (HMO SNP)
  • Medicare Advantage
  • Medicare Advantage PPO State Benefit Health Plan

For Hospitalizations at participating and non-participating acute care facilities.

Policy:

  1. Readmission review involves admissions to an acute care facility occurring less than 31 calendar days from the date of discharge from the same or another acute care facility. Neither the day of discharge nor the day of admission is counted when determining whether a readmission has occurred.
  2. Prior authorization of either hospitalization is not a guarantee of payment and Horizon reserves the right to review and combine reimbursement payments for readmissions.
  3. Reviews for readmission may be conducted prospectively, concurrently or retrospectively.
  4. Prospective/concurrent review
    1. For each Readmission hospitalization, the Notifications of Admissions (NOA) and/or clinical information provided for CCR will be reviewed for a Readmission hospitalization if:
      1. Index hospitalization discharge occurs less than 31 calendar days from Readmission hospitalization, AND
      2. Discharge is from the same facility
    2. If the Readmission hospitalization in question is deemed reviewable per 4.D.a., the CCR nurse:
      1. Will review the Readmission hospitalization notes available and compare against the Index hospitalization notes in the medical management system for:
        1. Premature Discharge of Patient That Results in Subsequent Readmission of Patient to Same Hospital;
        2. Readmission of Patient to Hospital for Care That Could Have Been Provided During First Admission; or
        3. Lack of coordination of care during the discharge transition.
      2. In reviewing the Readmission hospitalization and Index hospitalization notes, the CCR nurse will investigate for:
        1. Same or similar condition or diagnoses;
        2. Same, similar or related reason;
        3. Planned readmission; or
        4. Complication due to care, such as surgery, performed during index
      3. Excluded from readmission review:
        1. Discharge from Index hospitalization was against medical advice (AMA);
        2. Readmission that is planned for repetitive
        3. treatments (for example, cancer chemotherapy);
        4. Readmission is for scheduled elective surgery; and
        5. Maternity readmission.
    3. With the available information, the CCR nurse will either:
      1. determine whether the Readmission hospitalization meets the criteria in § 4.D. and review the Readmission hospitalization for medical necessity as per normal CCR process (Concurrent Review Policy, 31C.522)
      2. where the Readmission hospitalization meets the criteria as noted in §4.D, the CCR nurse will refer the Readmission hospitalization to the Horizon Medical Director for review.
    4. The Horizon Medical Director will make final determination regarding the Readmission hospitalization.
      1. If it is determined that the Readmission hospitalization meets the criteria in §4.D., the denial will be issued as a Readmission hospitalization denial.
        1. As a result of the denial, reimbursement for Readmission hospitalization will be combined with the Index hospitalization and the first payment will be considered payment in full for the two hospitalizations.
  5. Retrospective Review
    1. Medical records for both admissions will be requested and reviewed to determine if the Readmission hospitalization meets the criteria in §4.D.
    2. Failure of the provider to provide complete medical records from the Index hospitalization and Readmission hospitalization may result in denial of claims payment.
    3. When it is determined that the Readmission hospitalization met the criteria in §4.D, or was not medically necessary, the reimbursement for Readmission hospitalization will be combined with the Index hospitalization and the first payment will be considered payment in full for the two hospitalizations.

  6. Appeals process

    (Reference: Appeals Policy for Horizon Medicare Advantage Member, Policy 20141124-E479)

    1. Provider may appeal the denial of readmission (peer-to-peer and/or formal appeal)
  7. Planned readmission and use of leave of absence
    1. When a Readmission hospitalization is expected and the member does not require a hospital level of care during the interim period, the member may be placed on leave of absence by the provider.
      1. Examples include, but are not limited to, situations where surgery could not be scheduled immediately, a specific surgical team was not available, bilateral surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin immediately.
    2. Horizon expects providers to submit one claim for covered days and days of leave when the patient is ultimately discharged. The admissions are not considered two (2) separate admissions.
    3. During the above claims pends and review, Horizon may review cases for proper medical billing