HCA to revise Medicaid readmissions payment policy!

September 13, 2017

WSHA and member hospitals are participating a stakeholder group, along with the Medicaid managed care organizations (MCOs) to discuss HCA’s plan to revise its payment policy for potentially preventable hospital readmissions. HCA plans to return to a policy where readmissions within 14 days of a hospital discharge can be individually reviewed and denied if determined to be a provider preventable admission. The new proposal may apply to all hospitals, including critical access hospitals that are exempt from cuts under the current policy.  This new policy could result in greater savings to the MCOs than the current approach.

While HCA’s latest draft is an improvement from the initial draft and includes some recommendations from WSHA and member hospitals, we still have significant concerns.  Moving forward, WSHA and hospitals are advocating that the policy must include protections from blanket denials or pending of claims for readmissions not excluded from the criteria, expanded exclusion criteria to limit the administrative burden for certain disease categories that result in high rates of readmissions, and a fair and transparent appeals process.

We expect to see another draft of this policy in the next couple of weeks and we will share it with Chief Financial Officers and Chief Nursing Officers for input. HCA plans to finalize the policy in the next month for inclusion in the 2018 managed care contracts. Specific implementation details of the policy will be determined over time.  This new policy would replace the policy that has been in place since January 2016 which applies prospective payment rate penalties to hospitals that have higher than expected potentially preventable readmissions as determined through a 3M software program. For questions or comments, please contact Chelene Whiteaker, Senior Director, Policy Development at 206-216-2545 or by email. (Chelene Whiteaker, chelenew@wsha.org).


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