MA Readmission Quality Program

Blue Cross and Blue Shield of Nebraska (BCBSNE) Medicare Readmission Quality Program is part of the payment methodology we use to pay some facilities for services rendered to our Medicare Advantage (MA) members. The Readmission Review Program applies to all Blue Cross Blue Shield of Nebraska benefit plans and acute care facilities that are paid based on Medicare Severity Diagnosis Related Group (MS-DRG) payment methodology established by Centers for Medicare & Medicaid Services (CMS) published guidelines. This includes facilities that participate in BCBSNE MA care provider network as well as those that do not. The Readmission Review Program is allowed by CMS requirements and guidance. 
 
BCBSNE follows the guidelines established by the CMS for Same Day Readmissions, 30 day Readmissions, Planned Readmissions and Leave of Absence. CMS encourages facilities to improve communication and care coordination for patients and caregivers in discharge planning to reduce avoidable readmissions. Patients are more likely to have better outcomes, functional ability, survivability and quality of life.  

Review criteria 

The review criteria include but are not limited to the following:

• Readmissions related to the first admission
• Preventable readmissions 
• Premature hospital discharge from the same facility or a facility within the same health system or under the same provider contract 
• Unplanned surgery resulting in a continuation of the initial admission 
• Condition or procedure attributed to a readmission due to a failed surgical procedure or interventional service 
• Infection due to the initial admission 
• Medical necessity 
• Exacerbation of symptoms of a chronic illness 

Exclusions

• Admissions for the medical treatment of cancer, primary psychiatric disease and rehabilitation care or other similar repetitive treatments 
• Planned readmissions  
• Patient transfers from one acute care hospital to another  
• Patient discharged from the hospital against medical advice 
• Transplants 

As a provider what should I expect? 

• Blue Cross and Blue Shield Nebraska (BCBSNE) will perform a clinical review of acute care facility readmissions that occur within 30 days of discharge from the same hospital. 
• If BCBSNE determines that a provider has submitted a second claim after a patient has been discharged from an acute inpatient stay, medical records may be requested from the provider. 
• All days for the initial admission and readmission must receive prior authorization 
• BCBSNE will also review during authorization process whether the second admission is related to first admission. 
• Providers may dispute determinations through the provider appeals process. 
• If BCBSNE determines that the subsequent admits are a readmission BCBSNE will deny subsequent claims and only pay initial. 

As a provider what should I do?

• Upon request of medical records, the facility must forward related medical records and supporting documentation. 
• If it is determined that the acute stays were clinically related, BCBSNE may deny payment to the facility for the readmission.  

Resources 

Hospital Readmissions Reduction Program (HRRP) | CMS 

CMS Claims Processing Manual, Chapter 3 - Inpatient Hospital Billing 

CMS, Medicare Quality Improvement Organization (QIO) Manual. Readmission Review, Chapter 4, Section 4240 

MA specific rule sets  

The Readmission Review Program applies to all BCBSNE MA benefit plans and acute care facilities that are paid based on MS-DRG payment methodology established by CMS published guidelines. This includes facilities that participate in BCBSNE MA care provider network as well as those that do not. The Readmission Review Program is allowed by CMS requirements and guidance. 

Billing: This review is based on the CMS billing guidelines for same-day readmissions and leave of absence episodes.

• Quality-of-care: Incorporates readmission reviews into payment to facilities receiving MS-DRG payment, based on CMS guidelines. This program is based on MS-DRG reimbursement rules and isn’t a review for medical necessity. 

The readmission criteria for the program are as follows:

• The readmission occurred less than 30 days after the initial member discharge 
• The readmission was for a diagnosis related to the initial member admission 
• The readmission was at the same facility. If the criteria are met, we will request medical records and supporting documentation for the member’s initial discharge and admission. 

This policy does not apply to the following: 

• Transfer from one inpatient stay at an acute care hospital to an inpatient stay at another acute care hospital 
• Patient discharged from the hospital against medical advice 
• Planned readmissions for cancer chemotherapy, transfusion for chronic anemia or other similar repetitive treatments 
• Readmission for unrelated condition 
• Readmission for the medical treatment of rehabilitation care 
• Psychiatric and substance abuse (Behavioral Health) 
• Transplants 
• Critical Access Hospitals  

Following type of medical records: 

• Emergency room/admission records 
• Medical history 
• Consultations 
• Physician orders 
• Physician and nursing progress notes 
• Ancillary reports (e.g., laboratory reports, X-rays, medication administration records or treatment administration records) 
• Discharge summary 

If we do not receive complete medical records, an administrative denial letter will be issued stating which parts of the records are incomplete. The provider will be given the appeal rights with instructions for the process and an opportunity to submit the complete medical records for review. Both contracted and non-contracted health care professionals have reconsideration and appeals rights for denied claims. You can find specific information about your reconsideration or appeal rights in the letter we sent you. All claims denied under the Medicare Readmission Review Program are denied as a health care professional liability. This means a plan member isn’t liable for these denied claims, and you can’t balance bill a member for the denied claim. 

CMS readmission criteria: 

• Same-day readmission for a related condition  
• Same-day readmission for an unrelated condition  
• Planned readmission/leave of absence  
• Unplanned readmission less than 30 days after the prior discharge  

The Same-day readmission for a related condition, Same-day readmission for an unrelated condition and Planned readmission/leave of absence involve a determination of whether CMS and Nebraska billing requirements were followed. Unplanned readmission less than 30 days after the prior discharge involves a determination of whether the readmission was preventable. 

Same-day readmissions same or related condition: If a patient is readmitted to a facility on the same day as a prior discharge for the same or a related condition, CMS requires the facility to combine the two admissions on one claim. “Same day” is defined as midnight to midnight of a single day. CMS specifies the requirements in the Medicare Claims Processing Manual, Chapter 3, Section 40.2.5. Consistent with CMS billing requirements, BCBSNE may review claims for same-day readmissions and request medical records to determine if the claim was properly billed. If a patient was readmitted during the same day for the same or a related condition, BCBSNE will deny both the initial and subsequent admissions for payment as separate DRGs. The facility must submit both admissions combined on a single claim to receive reimbursement. For a same-day readmission to qualify for separate reimbursement, the medical record must support that the conditions are clinically unrelated. 

Same-day readmissions unrelated condition: If a patient is readmitted to a facility on the same day as a prior discharge for symptoms unrelated to the prior stay’s medical condition, CMS requires the facility to follow different billing requirements. In this situation, two claims are submitted, but the claim for the subsequent admission must contain condition code “B4.” The Medicare Claims Processing Manual, Chapter 3, Section 40.2.5 lists all CMS billing requirements. Consistent with CMS billing requirements, if a patient is readmitted during the same day for an unrelated condition, two properly coded claims must be submitted. 

Same-day and planned readmission/leave of absence: CMS has established billing requirements for facilities in Chapter 3 of the Medicare Claims Processing Manual. These administrative requirements address proper billing for same-day readmissions and planned readmissions/leaves of absence. Claims denied following review for preventable readmissions occurring less than 30 days after discharge remain subject to the billing guidelines if that denial is overturned. 

Planned readmission (leave of absence): If a patient is readmitted to a facility as part of a planned readmission or leave of absence, the admissions are not considered two separate admissions. CMS requires the facility to submit one claim and receive one combined DRG payment for both admissions because both are for the treatment of the same episode of illness. Leaves of absence are described in Chapter 3, Sections 40.2.5 and 40.2.6 of the Medicare Claims Processing Manual. Section 40.2.5 describes situations where leave of absence billing is appropriate. The medical records from the initial admission should indicate that additional work-up, treatment or surgical procedures are planned or expected for the same episode of illness. As required by Section 40.2.6, when the patient is ultimately discharged from the subsequent admission, the facility submits one bill for covered days and days of leave. Days of leave are included in FL 8, Non-Covered Days. The Medicare program may not be billed for days of leave, and the facility is not permitted to charge a beneficiary for them.  

When a readmission is expected but the date of readmission is different from that initially planned, the readmission should still be treated as a leave of absence, with one claim and one combined DRG payment. If the patient had to return early due to failed outpatient management and/or failed conservative management, it is still an expected readmission. Readmissions for surgical interventions that are expected when conservative and/or non-operative therapy have failed qualify for the Combined DRG review.  

Consistent with CMS billing requirements, BCBSNE may review claims for planned readmissions and request medical records to determine if the claim was properly billed. BCBSNE does not apply the leave of absence billing guidelines to cancer chemotherapy, transfusions for chronic anemia, or similar repetitive treatments. However, surgery that is delayed while outpatient work-up is completed does fall under the leave of absence billing guidelines. 

30-Day readmission review determination of preventable readmissions: 
As allowed by CMS, Blue Cross Blue Shield of Nebraska reviews acute care hospital admissions occurring fewer than 30 days following a prior discharge. Readmission review for 30 days is inherent in the CMS MS-DRG payment methodology and encouraged by Congress and the Medicare Quality Improvement Organization (QIO). In order to review preventable readmissions BCBSNE may request medical records related to both hospitalizations. CMS states reimbursement for readmissions may be denied (see Medicare QIO Manual, Chapter 4, Section 4240) if the readmission: 

• Was medically unnecessary  
• Resulted from a premature discharge from the same hospital  
• Was a result of circumvention of the PPS by the same hospital  

Review process and clinical guidelines 

The medical director will review the medical records to determine if the subsequent admission was preventable and/or there is an indication that the facility was attempting to circumvent the PPS system.  

To determine whether a patient’s discharge was preventable, the medical director will consider multiple factors including, but not limited to, premature discharge, inadequate discharge planning, clinical instability at the time of discharge and discharge to an inappropriate destination. In accordance with the requirements set out in the CMS State Operations Manual, Appendix A §482.43, discharge prior to completing adequate discharge planning will be considered a premature discharge and a preventable readmission. Clinical instability at the time of discharge or failure to address signs and symptoms during an admission is also evidence of premature discharge and a preventable readmission.  

The following factors related to discharge planning may be considered to determine if the discharge plan was inadequate and the subsequent admission was preventable. CMS provides guidance concerning proper discharge planning (see Medicare QIO Manual, Chapter 4, Section 4240 – Readmission Review, State Operations Manual Appendix A ‒ Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, Section A-0799 and the Code of Federal Regulations 42, Section 482.43 ‒ Discharge Planning).