SHBP/SEHBP Inpatient Readmission Reimbursement

Administrative Policy:
SHBP/SEHBP Inpatient Readmission Reimbursement

Effective Date:
October 1, 2021

Scope:
This policy only applies to members in the State Health Benefit Program (SHBP) and State Educators Health Benefit Program (SEHBP).

Purpose:
To outline the reimbursement practices concerning certain inpatient readmissions for Horizon BCBSNJ SHBP/SEHBP members. Excludes out state or out of network facilities not considered participating with the Horizon BCBSNJ hospital network.

Definitions:

Acute Care Facility is acute, general, short-term hospital.

Index Hospitalization is the initial hospitalization at an Acute Care Facility (hospital) where the discharge date occurred less than 31 days prior to the admission of the Readmission Hospitalization.

Readmission Hospitalization is a hospitalization at an Acute Care Facility (hospital) whose admission occurred less than 31 days after the Index Hospitalization’s discharge date.

Same or similar condition or diagnosis is a condition or diagnosis, which is the same or similar when compared between the Index Hospitalization and Readmission Hospitalization.

Prospective/Concurrent Review is a request for coverage of medical care or services made while a member is in the process of receiving the requested medical or behavioral care or services.

Retrospective Review is a request for coverage of medical care or services after a member has received the requested medical or behavioral care or services

Premature Discharge of Patient That Results in Subsequent Readmission of Patient to Same Hospital occurs when a patient is discharged even though he/she should have remained in the Acute Care Facility for further testing or treatment or was not clinically stable at the time of discharge. A patient is not clinically stable when, in Horizon’s judgment, the patient's condition is such that it is clinically unsound to discharge or transfer the patient. Evidence such as, but not limited to, elevated temperature, postoperative wound draining or bleeding, or abnormal laboratory studies or behavioral health instability that presents a danger to patient or others on the day of discharge may indicate that a patient may have been prematurely discharged from the acute care facility.

Readmission of Patient to Hospital for Care That Could Have Been Provided during First Admission occurs when a patient is readmitted to an Acute Care Facility for care that, pursuant to professionally recognized standards of health care, could have been provided during the first admission. This action does not include circumstances in which it is not medically appropriate to provide the care during the first admission.

Policy:

In cases where a review by Horizon of the circumstances indicates that the Readmission Hospitalization was:
1. The result of a premature discharge from the same hospital, or
2. Due to a lack of coordination in the transition of care between the Acute Care Facility and the outpatient setting, or
3. Such that the care rendered on readmission should reasonably have been provided during the Index Hospitalization.
Horizon shall not provide separate reimbursement for the Readmission Hospitalization if the Index Hospitalization was in the same Acute Care Facility.

Prior authorization of either the Index Hospitalization or the Readmission Hospitalization is not a guarantee of payment and Horizon reserves the right to review and combine reimbursement payments for readmissions based on the application of the review process and criteria below to the circumstances.
Reviews for Readmission Hospitalizations may be conducted prospectively, concurrently or retrospectively. For each Readmission Hospitalization, clinical information will be reviewed if there is an Index Hospitalization, AND the Readmission Hospitalization is to the same facility.

The review will include:
1. The Readmission Hospitalization treatment records/notes available in comparison to the Index Hospitalization treatment records/notes available in the medical management system. The comparison will endeavor to determine if any of the following are present:
  1. Premature Discharge of Patient that Results in subsequent Readmission of patient to Same Hospital;
  2. Readmission of Patient to Hospital for Care that could have been provided during the First Admission; or
  3. Lack of coordination of care during the discharge transition.
1. In reviewing the Readmission Hospitalization and Index Hospital treatment records/notes, the reviewer will investigate for the following:
  1. Same or similar condition or diagnosis,
  2. Same, similar or related reason;
  3. Complications due to care rendered during the Index Hospitalization; i.e. surgery.
1. Exclusionary factors to the above review criteria:
  1. Discharge from Index Hospitalization was against medical advice (AMA)
  2. Readmission was planned for ongoing, intentionally scheduled treatments (for example, cancer)
  3. Chemotherapy
  4. Readmission was for scheduled elective surgery
  5. Maternity readmission
  6. Involuntary admission (Behavioral Health)
  7. Court mandated (Behavioral Health)
  8. Admissions to a substance use disorder unit

Following the review of the available treatment records/notes/information, the reviewer will determine whether:
1. The Readmission Hospitalization meets the applicable criteria in the Definitions section above and review the Readmission Hospitalization for medical necessity as per normal admission review process
1. When the Readmission Hospitalization meets the applicable criteria as noted in the Definitions section above, the reviewer will refer the Readmission Hospitalization to the Horizon Medical Director for review and final determination.

The Horizon Medical Director will make the final determination of the Readmission Hospitalization.
1. If it is determined that the Readmission Hospitalization meets the applicable criteria in the Definitions section above, a denial will be issued as a Readmission Hospitalization denial.
1. As a result of the denial, reimbursement for the Readmission Hospitalization will be deemed combined with the Index Hospitalization and the first payment will be considered payment in full for both hospitalizations. All Horizon network participating Acute Care Facilities are required to honor Horizon’s determinations and must hold the Horizon member harmless for the cost of any such denied Readmission Hospitalization. Facility may request peer-to-peer or submit a formal appeal of the denial of separate reimbursement for the Readmission Hospitalization.

HCM-PP-UM-031-0621