The Health Care Authority (HCA) changed its Medicaid payment policy regarding preventable readmissions effective January 1, 2018. WSHA has been told by HCA that some hospitals are not responding to Medicaid managed care organizations’ (MCO) records requests to allow the MCOs to review the readmission. Records requests can go back to readmissions on/after January 1, 2018. We urge hospitals to cooperate with record requests regarding a potentially preventable readmissions. MCOs may deny claims if hospitals do not provide requested documentation. We also request that hospitals notify HCA and WSHA if you believe claims are inappropriately denied according to the policy. HCA has agreed to review cases where there is a dispute between the hospital and the MCO.
Under the new policy, developed by HCA in conjunction with WSHA and hospital leaders, the rate penalty is removed but managed care organizations (MCOs) may review and deny individual readmission claims determined to be preventable based on specific policy criteria. Please see our previous bulletin for more information. (Andrew Busz, email@example.com)