Reimbursement Policy:
Inpatient Readmission
Effective Date:
December 2, 2024
Revision Date:
N/A
Policy Last Review Date:
August 22, 2024
Purpose:
To provide guidance on the reimbursement of inpatient readmissions for Horizon NJ Health. This policy applies to all Acute Care Facility participating providers within the Horizon NJ Health network.
Scope:
Products included:
- NJ FamilyCare/Medicaid Plan
- Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)
Definitions:
- Acute Care Facility: Acute, general or specialty hospital, including acute hospital care at home.
- Index Hospitalization: The initial hospitalization at an Acute Care Facility.
- Readmission Hospitalization: A hospitalization occurring at an Acute Care Facility when admission date occurred less than 31 calendar days from an Index Hospitalization discharge date from the same Acute Care Facility.
Policy:
As further described herein, Horizon NJ Health shall not provide separate reimbursement for admissions with the same, or clinically similar, diagnoses at an Acute Care Facility when the admission occurred less than 31 calendar days from an Index Hospitalization discharge date from the same Acute Care Facility.
Reimbursement for the Readmission Hospitalization will be deemed combined with the Index Hospitalization and the payment for the Index Hospitalization will be considered payment in full for both hospitalizations. All Horizon NJ Health network participating Acute Care Facilities are required to honor Horizon NJ Health's determinations and must hold the Horizon NJ Health member harmless for the cost of any such denied Readmission Hospitalization.
This policy considers CMS inpatient readmission guidelines regarding the identification of a potentially avoidable readmission. Horizon NJ Health reserves the right to update this policy based on CMS readmission updates without further notice. Horizon's reimbursement rules for readmissions, as outlined below, do not mirror the current CMS reimbursement process for readmissions for traditional Medicare programs.
Horizon NJ Health shall not provide separate reimbursement of cases in which a review of the circumstances indicates that the Readmission Hospitalization was:
- Such that the care rendered on readmission could reasonably have been provided during the Index Hospitalization; or
- The result of a premature discharge from the same hospital as the Index Hospitalization, or
- Due to a lack of coordination in the transition of care between the Acute Care Facility and the outpatient setting.
Note: Authorization of either the Index Hospitalization or the Readmission Hospitalization is not a guarantee of payment. Horizon NJ Health reserves the right to review and consider reimbursement for each admission based on the application of Horizon NJ Health medical, reimbursement and other policies.
The review will include the Readmission Hospitalization treatment records/notes available in comparison to the Index Hospitalization treatment records/notes available in the medical management system.
Exclusionary factors to the Inpatient Readmission Policy include:
- Discharge from Index Hospitalization was against medical advice (AMA)
- Readmission was planned for ongoing, intentionally scheduled treatments (such as chemotherapy that require hospitalization, staged or scheduled elective surgery)
- Court mandated admission including involuntary admission for mental health treatment
- Admissions related to the treatment for;
- Sickle Cell crisis
- Elevated Lead levels
- Complication related to Transplant services
- Maternity related care
The Horizon NJ Health Medical Director shall make the final determination regarding denial or payment of the Readmission Hospitalization.
- If it is determined that the Readmission Hospitalization meets the applicable criteria above, the Readmission Hospitalization will be considered part of the index admission and will not be reimbursed separately.
- As a result of the denial of separate reimbursement for the Readmission Hospitalization, the readmission will be deemed combined with the Index Hospitalization and the first payment will be considered payment in full for both hospitalizations.
- All Horizon NJ Health network participating Acute Care Facilities are required to honor Horizon NJ Health determinations and must hold the Horizon NJ Health member harmless for the cost of any such Readmission Hospitalization. Facility may submit a formal appeal of the denial of separate reimbursement for the Readmission Hospitalization.
Procedure:
Horizon NJ Health shall deny claims that fail to meet this policy's criteria for payment.
In cases of denied reimbursement for readmission, where the Acute Care Facility is participating in Horizon NJ Health network, there shall be no member liability.
Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:
- Benefit Limitations;
- The terms of any applicable provider participation agreement;
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
- Medical necessity; and
- Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.
History:
08/22/2024: Policy Approved
