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Inpatient Readmissions Policy

According to the Centers for Medicare & Medicaid Services (CMS), hospital readmissions have been proposed as a quality of care indicator because they may result from actions taken or omitted during a member’s initial hospital stay. Based on a 2008 CMS report, an estimated $12 billion out of $15 billion is spent on preventable readmissions. 

Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program. A readmission is defined as an admission to a hospital within 30 days of a discharge from the same or a similar hospital. The 30 day ruling is subject to state approval and alteration.    

A readmission occurs when a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital within 30 days for symptoms related to, or for evaluation and management of, the prior stay’s medical condition, hospitals shall adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim. 

Policy

Pursuant to Medicare and Medicaid guidelines, WellCare implemented a process of reviewing, adjudicating, and adjusting claims payments for inpatient admissions that are deemed to be a readmission.

Procedure

  • WellCare reserves the right to look back within the maximum allowed recovery time frame per state guidelines or per specific provider contract to identify any claims that may be readmissions.
  • WellCare will identify claims that are most likely readmissions for denial or request a refund.
  • If the provider disagrees with WellCare’s determination, the provider has the right to appeal/dispute the determination. The provider must submit medical records for both admissions and WellCare will evaluate the records to determine if the second admission is a readmission of the first admission.
  • If it is determined that the second record is not a readmission, the provider will be notified and no additional actions will occur.
  • If WellCare determines that the second admission is a readmission of the first, the provider will be notified that the denial or requested refund will be upheld.

 

Readmissions days vary by state and CMS. Below is the breakdown of the maximum amount of time for an admission to be potentially classified as a readmission. When the state is silent, WellCare will use the CMS definition.

Medicare

State Readmissions Days Source
Medicare 30 Section 3025 Section 1886(q)

Medicaid

State Readmissions Days Source
Florida 30  CMS Definition
Georgia 3 Georgia Medicaid Hospital Handbook, § 904
Illinois 30 89 Ill. Admin. Code 152.300
Kentucky 14 907 KY ADC 10:825
Nebraska 31 CMS Definition
New Jersey 7 NJ ADC 10:52-14.16
New York 14 10 NY ADC 86-1.37
South Carolina 30 CMS Definition 

 

Frequently Asked Questions

1. Why is WellCare implementing this policy?
This is not a new policy. The WellCare Medicare Advantage and Medicaid Provider Manuals address inpatient readmission guidelines. Instead, WellCare is executing readmission criteria published by federal and state agencies.  

2. Why can I not bill the member if WellCare does not pay the claim?
Pursuant to the terms in your contract, participating providers are not permitted to balance bill members for claims that are denied by WellCare. 

3. How do I dispute/appeal a readmission determination?
To dispute or appeal a determination, please mail  a summary of the appeal or reconsideration request, the member’s name, member’s identification number, date of service(s), reason(s) why the denial should be reversed and copies of related documentation and all applicable medical records related to both stays to support appropriateness of the services rendered to the following addresses:

Attn: WellCare Medical Review Unit

CONNOLLY HEALTHCARE
555 North Lane, Suite 6125
Conshohocken, PA 19428
Fax: (203) 529-2985

 

4. What documentation do I need to submit with my dispute/appeal?  

INCLUDE (as applicable) EXCLUDE

Consultations

Consent Forms

 Case Management Notes/Social Work Notes Dietary Notes
Diagnostic testing results i.e. EKG, Echocardiogram, Laboratory Reports, X-Ray Duplicate Pages
Discharge Instructions Flow Sheets
Discharge Medication List Holter Monitor Tracings
Discharge Summary  
Therapy Notes  
ER Report  
History and Physical  
Itemized Bill  
MAR (Medication Administration Record)  
Nursing Notes  

Operative Report

 

Pathology Report

 
Physician Orders  
Physician Progress Notes  
Respiratory/Ventilation Sheets  

TAR (Treatment Administration Record)

 
UB 92 or UB 04 form  

 

5. Where do I send refund a check?
If you wish to send in a refund, send the check and a copy of the overpayment request letter to the following address. It is important to send a copy of the letter so that the refund gets correctly applied to your account.

WellCare
Recovery Department
PO Box 31584
Tampa, FL 33631-3584


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Last Updated On: 3/3/2017