Blue Cross implements post-pay audits related to inpatient readmissions

In 2019, Blue Cross Blue Shield of Michigan implemented post-pay audits related to inpatient readmissions for all Medicare Plus Blue℠ members.

Blue Cross contracted with HMS^® to conduct audits for readmissions to the same facility occurring up to 30 days from the date the patient was released from the hospital if the readmission is related to the prior medical condition. This applies to both contracted and non-contracted hospitals that are reimbursed at a diagnosis-related group case rate. Hospitals can no longer rebill Medicare Part B services from the denied admission.

HMS’ initial letter will contain findings that medical conditions causing the readmission appear to be related to the prior medical condition. If the hospitals disagree with HMS’ decision, hospitals can submit a reconsideration request and submit medical records on appeal for all listed claims on the HMS letter (including the reference claim). If no medical records are submitted, we will recoup payment on the readmitted claim on the HMS letter.

How to request a reconsideration review:

• Gather the full medical record documentation requested for all listed claims in the letter (include reference claim records).
• Make sure all pages are complete, legible and include both sides and page edges where applicable.
• Attach a copy of the claim list to the medical records and highlight the claim numbers.

Hospitals are responsible for all costs pertaining to readmissions denied under the Medicare Plus Blue Readmissions Reimbursement Policy. They aren’t allowed to charge or balance bill Medicare Plus Blue members for the denied stay.

The following are exclusions to this policy:

• Professional services related to the readmission
• Admissions for chemotherapy or immunotherapy treatment
• Admissions to a substance abuse unit or facility
• Admissions to an inpatient rehabilitation unit
• Readmission after a patient is discharged from the hospital against medical advice
• Admissions for covered transplant services during the global case rate period for the transplant

Questions?

If you need to speak to an HMS representative during an audit, call 1-866-875-1749 from 9 a.m. to 7:30 p.m. Eastern time Monday through Friday.