This policy applies to participating hospitals and hospital health systems reimbursed based on DRG/case rate methodologies. The policy does not apply to participating hospitals and hospital health systems reimbursed on a per diem basis. The policy does not apply to non-participating hospitals and hospital health systems.
READMISSION WITHIN 30 DAYS OF INPATIENT DISCHARGE
Acute care hospital stays (i.e., both inpatient and observation stays) to the same acute care hospital, or an acute care hospital within the same health system, within 30 days of discharge from the previous inpatient stay and/or for a condition related to the original inpatient stay (e.g., the same major diagnostic category [MDC], a post-operative infection, sepsis, or complication diagnosis), are not eligible for separate reimbursement when each hospital stay is paid per DRG or case rate. This will eliminate the payment of multiple case rates for a single clinical event.
For purposes of reimbursement, when the above criteria are met, the Company will treat all acute care hospital stays as a single clinical event. The claim with the higher payment will remain in place, and the claim(s) for the other related stays(s) will be retracted post payment.
CLAIM RETRACTIONS
Claim retractions will occur based on a retrospective claim audit review. Hospitals will be notified prior to any retrospective claim retraction and will be afforded the facility audit review process for dispute resolution.
POLICY EXCEPTIONS
This policy does not apply to the services listed below:
- Maternity and newborn care, with the exception of subsequent stays (e.g., readmission) for a condition directly related to the delivery, such as infection, post C-section ileus or other C-section or vaginal delivery complications
- Planned elective hospital stays (e.g., chemotherapy)
- Transplant services
- Acute care transfers from one institution to another within the same health system
- A condition unrelated to the original inpatient stay
- Discharge from the hospital against medical advice
- Behavioral health, psychiatric, and/or drug and alcohol hospital stays
- Acute physical rehabilitation
REQUIRED DOCUMENTATION
At the request of the Company or one of its affiliates, the hospital(s) must submit medical records and supporting documentation pertaining to the original inpatient stay and subsequent stay(s). Medical records requested must include the following information:
- Admission and discharge summaries
- Physician orders
- Emergency room records
- Progress notes
- Nurse notes
- Laboratory and diagnostic testing reports
- History and physical
