These frequently asked questions (FAQ) were developed to answer questions about the expansion of the AmeriHealth policy regarding inpatient hospital readmissions. Our Claim Payment Policy #00.01.47c: Inpatient Hospital Readmission went into effect January 15, 2017, and was expanded to include a provision for readmission within 6 ? 30 days of discharge.

Note: This document will be updated as additional information becomes available.

1. Why has AmeriHealth adjusted its policy on inpatient hospital readmissions?

At AmeriHealth we face an important challenge: balancing our commitment to fairly and competitively compensate physicians and hospitals with our responsibility to keep health care affordable for our members. As stewards of our members? and customers? health care dollars, we believe that using industry benchmarks and best practice standards to identify where we are outliers in health care costs and utilization is a necessary process. As such, we have identified areas that need to be adjusted to ensure we are appropriately reimbursing providers for the care they deliver to our members.After careful consideration was given to peer-reviewed literature and attention both regionally and nationally, our policy on inpatient readmissions was identified as an area that needed modification. This policy change reflects an industry-wide recognition that roughly a quarter of hospital readmissions are preventable through the provision of higher-quality care and improved transition planning, though this number can range as high as 79 percent.¹ The Centers for Medicare & Medicaid Services (CMS) and private payers alike have modified their reimbursement policies to incentivize providers to ensure patients are neither discharged prematurely nor discharged without the support they need to recover.

2. What does the adjustment to the policy mean?

Any readmission to the same inpatient acute care hospital, or inpatient acute care hospital within the same health system, within the time frame of 6 ? 30 days of the original admission will be subject to medical chart review to determine if the readmission was (1) related to the original inpatient hospital stay (including, but not limited to, same major diagnostic category [MDC], post-operative infection, sepsis, or complication diagnosis) and (2) determined to be preventable or avoidable. If the medical chart review indicates that the readmission was (1) related to the original inpatient hospital stay and (2) determined to be preventable or avoidable, the claim representing the readmission will be retracted post-payment. For the purpose of claim payments on multiple readmissions meeting the criteria above, when each inpatient hospital stay is paid per case or per admission, the claim for the initial inpatient acute-care hospital stay will remain in place and the claims for the other related readmissions will be retracted.

3. Which hospitals are affected by the policy?

The policy applies to participating inpatient acute care hospitals or a participating inpatient acute care hospital within the same health system that are paid per-case or per-admission for inpatient stays. This includes multiple readmissions to the same participating acute care hospital or a participating inpatient acute care hospital within the same health system when each inpatient hospital stay is paid per-case or per-admission.

4. Which criteria will be used to determine if the admission and readmission are directly related?

The criteria that will be used during the medical chart review to determine if the readmission is (1) related to the original inpatient hospital stay and (2) determined to be preventable or avoidable includes, but is not limited to, the following:

• acute decompensation of a coexisting chronic disease that may be related to care during the initial admission or follow up care after discharge (e.g., admission for uncontrolled diabetes after initial admission for asthma);
• an acute medical complication or post-operative complication related to care during the initial admission or post-discharge care (e.g., urinary tract infection as a result of urinary catheter placement at the initial admission, deep venous thrombosis following surgery to repair hip fracture, post-operative wound requiring drainage following initial admission for abdominal surgery);
• an unplanned surgery or admission to address a continuation or recurrence of the same problem as the initial admission (e.g., individual readmitted for cholecystectomy following initial admission for fever and elevated liver function tests or readmission for congestive heart failure after an initial admission for congestive heart failure);
• a condition or procedure indicative of a failed surgical or procedural intervention (e.g., repeat admission for an endoscopic intervention for gastrointestinal bleeding);
• a need that could have reasonably been prevented by the provision of appropriate care consistent with accepted standards in the prior discharge or during the post discharge follow up period (e.g., readmission for heart failure if individual did not have sufficient follow-up instructions to refill diuretic prescription);
• an issue caused by a premature discharge from the same inpatient acute care hospital, or an inpatient acute care hospital within the same health system.

5. What documentation is required when responding to the audit?

The following information should be included, along with any other supportive documentation, if applicable:

• admission and discharge summaries
• physician?s orders
• emergency room records
• progress notes
• nurse?s notes
• laboratory and diagnostic testing
• patient history and physical

6. How will the expanded policy be enforced?

This policy will be enforced through a retrospective claims audit. If the medical chart review indicates that the readmission to the same inpatient acute care hospital or an inpatient acute care hospital within the same health system was (1) related to the original inpatient hospital stay and (2) determined to be preventable or avoidable, the claim representing the readmission will be retracted post-payment.

7. If a claim is retracted, is the patient liable for copayment, deductible, or coinsurance amounts associated with the retracted claim?

No. The copayment, deductible, or coinsurance amounts for which the member is responsible should only apply to the claim that is not retracted. All copayment, deductible, or coinsurance amounts applied to the readmission(s) should be refunded by the facility once all dispute rights have been exhausted.

Note: The member will receive an Explanation of Benefits (EOB) with retraction code E6188, stating the member is held harmless for any cost-share. The following language will appear on the member?s EOB: ?Based on retrospective review, this claim is not separately payable.?

8. Does the expanded policy apply to transfers?

No. Transfers from one institution to another are not considered readmissions.

9. Does the expanded policy affect physician claims?

10. What are the differences between the 0 ? 5 day and 6 ? 30 day provisions in the policy?

Readmission within five days of discharge, for the purposes of this policy, is an unplanned inpatient acute care hospital readmission within five days of the previous inpatient hospital stay for a condition related to the original inpatient hospital stay (including, but not limited to, same MDC, post-operative infection, sepsis, or complication diagnosis).

Multiple readmissions, under the five-day readmission provision, are two or more unplanned inpatient acute care hospital admissions within five days of discharge from the most recent inpatient hospital date of discharge and for a condition related to the most recent inpatient hospital stay (including, but not limited to, same MDC, post-operative infection, sepsis, or complication diagnosis). For purposes of payment (when the above criteria are met), AmeriHealth will treat all inpatient hospital admissions as single clinical events. The claim with the highest payment will remain in place, and the claims for the related readmissions will be retracted.

Readmission within 6 ? 30 days of discharge, for the purposes of this policy, is an unplanned inpatient acute care hospital readmission within 6 ? 30 days of the previous inpatient hospital stay for a condition (1) related to the most recent inpatient hospital stay (including, but not limited to, same MDC, post-operative infection, sepsis, or complication diagnosis), and (2) determined to be preventable or avoidable.

The 6 ? 30 day readmission provision includes the day of discharge and the following 30 calendar days.

Multiple readmissions, under the 6 ? 30 day readmission provision, are two or more unplanned inpatient acute care hospital readmissions within 6 ? 30 days of discharge from the most recent inpatient hospital date of discharge and for a condition (1) related to the most recent inpatient hospital stay (including, but not limited to, same MDC, post-operative infection, sepsis, or complication diagnosis) and (2) determined to be preventable or avoidable.

Multiple readmissions are not eligible for separate reimbursement, when each inpatient hospital stay is paid per case or per admission. This eliminates payment of multiple rates. For the purpose of claim payments on multiple readmissions meeting the criteria above, when each inpatient hospital stay is paid per case or per admission, the claim for the initial inpatient acute-care hospital stay will remain in place and the claims for the other related readmissions will be retracted.

11. What is the 6 ? 30 day readmission audit and dispute process?

Claims submitted for readmission to the same inpatient acute care hospital, or a participating inpatient acute care hospital within the same health system, within the time frame of 6 ? 30 days of the original admission are subject to a medical chart review to determine if the readmission was (1) related to the original inpatient hospital stay and (2) determined to be preventable or avoidable.

If the claim(s) is determined to be related to the original admission and the readmission was preventable or avoidable, a communication will be sent to the facility requesting medical charts and other supporting documentation within 30 days of the date of the notification.

If the medical charts and supporting documentation are received within 30 days of the request, the audit review process begins. Medical charts and supporting documentation will be reviewed by a physician to determine if the medical chart and supporting documentation received show that the readmission claim(s) is (1) related to the original inpatient hospital stay and (2) preventable or avoidable.

Note: Only a physician can make a final determination.

Once a final determination has been made by a physician as to whether the readmission(s) was (1) related and (2) preventable or avoidable, notification with the decision, along with instructions on the dispute process, will be mailed to the facility.

If medical charts and supporting documentation are not received within 30 days of the request, the readmission claim(s) will be retracted; however, providers can still submit documentation through the first-level dispute process. Instructions for the dispute process will be included in the notification letter that advises of the claim retraction due to non-response.

For medical charts submitted within the 30-day time frame of the request, there is a two-level review process available for dispute resolution. A notification and instructions for the review process will be provided when you receive an audit determination notification.

If medical charts are not received within 30 days of the initial request, providers can still submit documentation through the first-level dispute process. Instructions for the dispute process will be included in the notification letter that advises of the claim retraction due to non-response.

12. What happens if I receive a chart request letter and the supporting documentation is not received within 30 days of the date of the notification?

If supporting documentation is not received within 30 days of the date of the request for both the initial and readmission stays, you will receive notification that the readmission claim(s) will be retracted along with instructions on the dispute process.

For more information

Please refer to our Medical Policy Portal to view the most recent version of the policy, as it will supersede the information in this FAQ.

If you cannot find the information you are looking for here and have further questions, please email us at
6-30dayreadmission@amerihealth.com.

You can download a PDF of this FAQ here.

¹https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080556/