According to the Centers for Medicare & Medicaid Services (CMS), hospital readmissions have been proposed as a quality of care indicator because they may result from actions taken or omitted during a member’s initial hospital stay. Based on a 2008 CMS report, an estimated $12 billion out of $15 billion is spent on preventable readmissions.
Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program. A readmission is defined as an admission to a hospital within 30 days of a discharge from the same or a similar hospital. The 30 day ruling is subject to state approval and alteration.
A readmission occurs when a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital within 30 days for symptoms related to, or for evaluation and management of, the prior stay’s medical condition, hospitals shall adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim.
Pursuant to Medicare and Medicaid guidelines, WellCare implemented a process of reviewing, adjudicating, and adjusting claims payments for inpatient admissions that are deemed to be a readmission.
- WellCare reserves the right to look back within the maximum allowed recovery time frame per state guidelines or per specific provider contract to identify any claims that may be readmissions.
- WellCare will identify claims that are most likely readmissions for denial or request a refund.
- If the provider disagrees with WellCare’s determination, the provider has the right to appeal/dispute the determination. The provider must submit medical records for both admissions and WellCare will evaluate the records to determine if the second admission is a readmission of the first admission.
- If it is determined that the second record is not a readmission, the provider will be notified and no additional actions will occur.
- If WellCare determines that the second admission is a readmission of the first, the provider will be notified that the denial or requested refund will be upheld.
Readmissions days vary by state and CMS. Below is the breakdown of the maximum amount of time for an admission to be potentially classified as a readmission. When the state is silent, WellCare will use the CMS definition.
|Medicare||30||Section 3025 Section 1886(q)|
|Georgia||3||Georgia Medicaid Hospital Handbook, § 904
|Illinois||30||89 Ill. Admin. Code 152.300|
|Kentucky||14||907 KY ADC 10:825|
|New Jersey||7||NJ ADC 10:52-14.16|
|New York||14||10 NY ADC 86-1.37|
|South Carolina||30||CMS Definition|
Dagiti Masansan a Saludsod
Attn: WellCare Medical Review Unit
4. What documentation do I need to submit with my dispute/appeal?
|INCLUDE (as applicable)||EXCLUDE|
|Case Management Notes/Social Work Notes||Dietary Notes|
|Diagnostic testing results i.e. EKG, Echocardiogram, Laboratory Reports, X-Ray||Duplicate Pages|
|Discharge Instructions||Flow Sheets|
|Discharge Medication List||Holter Monitor Tracings|
|History and Physical|
|MAR (Medication Administration Record)|
|Physician Progress Notes|
TAR (Treatment Administration Record)
|UB 92 or UB 04 form|
WellCare is implementing the following policy for Short Inpatient Hospital Stays effective on 01/01/2021 for Medicare plans.
Summary of Policy:
Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.
What does this mean for providers?
It is the policy of health plans affiliated with Centene Corporation® that inpatient hospital stays (vs. observation) of 2 days or less are medically necessary for one of the following indications:
Admission is for a procedure on the CMS Inpatient Only List, (addendum E found here);
Admission to an intermediate or intensive care unit level of care (including neonatal intensive care unit (NICU) considered medically necessary per a nationally-recognized clinical decision support tool;
Unexpected death during the admission;
Departure against medical advice from a medically necessary (per a nationally-recognized clinical decision support tool) inpatient stay;
Transferred from another facility, with a medically necessary (per a nationally-recognized clinical decision support tool) total length of stay greater than 2 days;
Election of hospice care in lieu of continued treatment in hospital.
Note: The policy at the link below will provide background and references for medical record review.
To review the complete policy please visit https://www.wellcare.com/providers, select Louisiana, then select Clinical Guidelines.
We are here to help. If you need further information, please contact your Network Representative.