December 19, 2019
Consistent with the Centers for Medicare & Medicaid Services (CMS) guidelines, beginning March 1, 2020, Blue Cross and Blue Shield of Oklahoma (BCBSOK) will review inpatient hospital claims for Medicare Advantage members, both PPO and HMO, to determine if readmissions to the same facility within 30 days of discharge are clinically related. If so, BCBSOK may deny payment to the facility for the related readmissions. These changes help support quality of care improvement efforts by linking payment to the quality of facility care for our Blue Cross Medicare Advantage members.
As a provider what should I expect?
- Beginning March 1, 2020, BCBSOK will perform a clinical review of acute care facility readmissions that occur within 30 days of discharge from the same facility.
- If BCBSOK determines that a provider has submitted one or more claims for inpatient admissions occurring within 30 days after a patient has been discharged from an initial acute inpatient stay, BCBSOK may request medical records from the provider.
As a provider what should I do?
- Upon request of medical records, the facility must forward related medical records and any documents involving the admissions.
- If it is determined that the acute stays were clinically related, BCBSOK may deny payment to the facility for the readmission(s).
- Providers may dispute determinations through existing processes.
- Visit the CMS Medicare Claims Processing Manual, section 40.2.5 for Repeat Admissions.
- If you have questions, contact your Network Management Consultant.