Summary
Blue Cross updated the inpatient readmission reimbursement policy to include Medicare Advantage plans on March 4, 2019. Blue Cross will not reimburse institutional claims for readmissions found to be preventable based on Centers for Medicare & Medicaid Services and clinical guidelines.
The purpose is to more effectively monitor the quality of care for Blue Cross members and reduce preventable hospital readmissions. By working with provider partners to reduce preventable hospital readmissions, Blue Cross aims to create better outcomes and experiences for members while limiting unnecessary health care costs. This reimbursement policy applies to clinically-related preventable readmissions occurring at the same hospital as the prior admission.
Timeframes for preventable readmission reviews based on line of business
Commercial/FEP members – 10 days (no change)
Medicare Advantage members – 30 days (new policy)
Exemptions
- Intervening admissions to non-acute care facilities are not considered readmissions and are therefore exempt from this policy.
- Readmissions that are not clinically-related are exempt from this policy. Clinically-related readmissions are a result of the process of treatment and care during the previous admission, or from a lack of post-admission follow-up. Unrelated events that occur following the prior admission are not considered potentially preventable.
- Readmissions to a different acute care facility from the prior admission are exempt from this policy.
- A readmission occurring within zero and one day related to the prior admission is considered part of the original admission and should be combined with the original claim.
- Admission for the medical treatment of cancer, primary psychiatric disease, rehabilitation, neonatal or obstetrical care, ophthalmic emergencies, sickle cell crisis, transplants, and hospice care are exempt from this policy for all lines of business.
- Planned readmissions or patients discharged against medical advice are exempt from this policy.
More information
Provider bulletin
A provider bulletin outlining this update to the inpatient readmission reimbursement policy was posted on January 2, 2019.
See latest provider bulletins and quickpoints
Reimbursement policy update
The updated facility inpatient readmission reimbursement policy (PDF) was posted on January 2, 2019, outlining the specific details and review criteria associated with this initiative.