Effective January 1, 2018, HCA will be increasing payment rates for those facilities that were previously penalized under the current policy for having higher than average readmissions rates according to the algorithm. Critical access hospitals are excluded from this policy change, consistent with the HCA’s current policy.
In late August HCA announced it was working on a new policy for readmissions. WSHA worked closely with a handful of key hospital leaders and HCA in this process. We believe the policy will help advance best practices for better patient care and support hospitals’ efforts to reduce readmissions. The latest version shows vast improvement from the initial drafts. In the discussions, we advocated successfully to:
- limit the numbers of readmissions that could be considered through clear exclusion criteria for psychiatric and substance use disorders, cancer related care, and other conditions;
- remove a very problematic provision to combine Diagnostic Related Groups and permit insurers to not pay for obstetrical readmissions and other planned or staged services with multiple and necessary admissions within 14 days;
- require the MCOs to pay the claim and to then show that the patient’s readmission was a result of a hospital’s action or inaction (the initial policy would have allowed blanket denials of claims);
- involve HCA in the dispute process and allow a hospital to trigger an audit; and
- clarify hospital/provider role in discharge planning.
WSHA appreciates HCA’s willingness to engage in important policy and quality discussions around this work.
- Review and understand the changes in the 2018 policy.
- Identify new ways to standardize the discharge process. Documentation in each patient’s chart of the discharge process and contact with the MCOs will be much more important for Medicaid patients moving forward.
WSHA will be actively engaging with HCA during 2018 as this policy is implemented. The Washington Administrative Code will also be updated to reference this new payment policy. We are also interested in hearing from hospitals if problems arise after implementation.
HCA is interested in continuing the discussions about combining DRGs for certain conditions. WSHA will be actively engaged in that discussion moving forward.