Unless otherwise stated in the facility contract, our policy is to deny readmissions within 30 days of discharge and consider them a part of the original admission. 

• Medicaid and the Healthy Michigan Plan define readmissions as within 15 days of discharge.
• Same-day readmissions are considered a continuation of care and one claim should be submitted.

Payment guidelines for readmissions

Use the list below to see when a second DRG or episode of care is payable. Guidelines 1-6 supersede 7-8 when more than one apply.

One allowable payment

1. Patient discharged:

a) before all medical treatment is rendered or

b) without an adequate or sustainable discharge plan that prevents readmission or

c) where care during the second admission could have occurred during the first admission 

Financial recovery: If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher

Appeal rights

Applies to all plans (15-day readmissions for Medicaid)

Examples:

• Medication reconciliation is not complete/accurate
• The medication route/frequency and purpose are not clearly communicated for all discharge medications
• The follow-up appointment with the patient's provider is not scheduled in an appropriate time frame (based on patient risk) and/or is not documented on the discharge instructions
• The signs and symptoms to watch for post-discharge are not documented and/or there is no clear action plan in the event of their occurrence

 

2. Patient discharged to allow resolution of a medical problem that, unless resolved, is a contraindication to the medically necessary care that will be provided during a planned second admission 

Financial recovery: If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher

Appeal rights

Applies to all plans (15-day readmissions for Medicaid)

Examples:

• Discharged to await normalization of clotting times prior to a surgical intervention. The medical necessity for interruption of care must be clearly documented.
• Patient has ankle fracture, internal fixation scheduled for 7-10 days

 

3. Patient-requested discharge because of uncertainty about whether or not to undergo further treatment or for other personal reasons, is readmitted for definitive care 

Financial recovery: If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher

Appeal rights

Applies to all plans (15-day readmissions for Medicaid)

Example: Newly diagnosed pelvic mass requiring surgery. Patient requests surgery after the holidays.

 

4. Patient discharged from the hospital but readmitted within 30 days with a direct or related complication from the first admission 

Financial recovery: If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher.

Appeal rights

Applies to all plans (15-day readmissions for Medicaid)

Example: An open appendectomy is performed. The patient returns in 3-5 days with a wound infection requiring hospitalization.

 

5. Patient discharged from the hospital with a documented plan to readmit within 30 days for additional services, excluding chemotherapy or staged surgical procedures 

Financial recovery: If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher

Appeal rights

Applies to all plans (15-day readmissions for Medicaid)

Example: Administrative reasons, e.g. surgeon was not available

 

6. Patient requires readmission due to a recurrence of the same condition 

Financial recovery: If lower DRG/episode of care is paid, adjustment made to recover dollars and pay the higher

Appeal rights

Applies to all plans (15-day readmissions for Medicaid)

Example: COPD or CHF exacerbation

 

Two allowable DRG payments or episodes of care

7. Patient requires readmission due to an unrelated condition.

Financial recovery: None

Appeal rights N/A - Second admit is payable

Applies to all plans (15-day readmissions for Medicaid)

Examples:

• Pregnancy/delivery first admission
• Readmission with a fractured ankle

 

8. Newborn infants readmitted within 30 days. 

Financial recovery: None

Appeal rights N/A - Second admit is payable

Applies to all plans (15-day readmissions for Medicaid) 

Example: Newborn readmitted with hyperbilirubinemia

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Requesting readmission reimbursement

The facility may appeal a readmission denial based on readmission guidelines and/or contract. Log into your prism account to submit an appeal with medical documentation.

• All readmissions are reviewed against Priority Health readmission guidelines.
• Determinations for approval or denial are made based on readmission guidelines and/or a Medical Director decision.