We’ll be starting Medicare Plus Blue readmission audits in September

Blue Cross Blue Shield of Michigan is implementing post-pay audits related to inpatient readmissions for all Medicare Plus Blue^SM PPO members.

Beginning with service dates on or after Sept. 1, 2019, we won’t reimburse for a readmission to the same facility occurring less than or equal to 30 days from the date the patient was released from the hospital if the readmission is related to the prior medical condition. This applies to both contracted and non-contracted hospitals that are reimbursed at a diagnosis-related group case rate. Hospitals can no longer rebill Medicare Part B services from the denied admission.

Medical records from each admission will be requested by HMS, an audit company that works with Blue Cross. Hospitals are required to provide their records for review. If the audit reveals that the medical conditions appear to be related, HMS will review the charts further to help ensure that appropriate discharge and completion of care procedures were followed.

The audit findings will be provided to the hospitals. If HMS finds the care isn’t related, the hospital will receive a no-findings letter. If HMS finds the care for both hospital visits is related, the case summaries and the rationale used in the decision to deny the readmission will be provided to the hospitals.

Hospitals can appeal the vendor decision by following the appeals process described in the Medicare Plus Blue PPO manual.

Hospitals are responsible for all costs pertaining to readmissions denied under the Medicare Plus Blue PPO Readmissions Reimbursement Policy. They aren’t allowed to charge or balance bill Medicare Plus Blue PPO members for the denied stay.

Exclusions

The following are exclusions to this policy:

• Professional services related to the readmission
• Admissions for chemotherapy or immunotherapy treatment
• Admissions to a substance abuse unit or facility
• Admissions to an inpatient rehabilitation unit
• Readmission after a patient is discharged from the hospital against medical advice
• Admissions for covered transplant services during the global case rate period for the transplant

Questions?

If you need to speak to an HMS vendor representative during an audit, call 1‑866‑875‑1749.