Readmission Quality Program

Under the Hospital Readmissions Reduction Program, facilities are encouraged 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

• Psychiatric or substance abuse admissions
• Transplant services admissions
• Readmission due to discharges against medical advice (medical record review is required for determination)
• Multiple trauma
• Burns
• Neonatal and obstetrical admissions
• Staged procedures associated with elective admissions following commonly accepted practices
• Transfer from an out-of-network to an in-network facility
• Transfer due to level of care unavailable at the first facility
• Planned readmission for cancer or chemotherapy treatment as the principal condition
• Hospice care

As a provider, what should I expect?

• Blue Cross and Blue Shield of Nebraska (BCBSNE) will perform a clinical review of acute care facility readmissions that occur within 30 days of discharge from the same health care system. 
• 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 be prior authorized. 
• Providers may dispute determinations through the provider appeals process.
• The reimbursement will be determined using either the initial admission or the readmission based on which claim has the greater total allowed amount.
• Multiple readmissions will not be separately reimbursed when each stay is reimbursed per case/per admission.
• If initial admission has been reimbursed, the original and readmission claims will be combined to determine reimbursement.

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. The facility may submit a corrected single claim for both inpatient stays. 

Resources

• Hospital Readmissions Reduction Program