Readmission Policy (Medicaid) – FAQ

30-Day Hospital Readmissions Policy – Frequently Asked Questions


Q1. How is Horizon NJ Health changing its hospital readmissions policy?

A1. In an effort to focus on quality of care, we will no longer reimburse providers for any costs related to a readmission to the same acute care hospital within 30 calendar days from a hospital discharge for same and/or similar diagnosis.

Q2. Why is the issue of hospital readmissions so important?

A2. Hospital readmissions within 30 days of discharge from an inpatient hospital stay is a poor quality of care outcome.

Q3. Is there a review process for these readmission cases?

A3. Yes, Horizon NJ Health recognizes that there are times when a readmission is warranted based on a change in clinical condition. To assure appropriateness of readmissions, the Horizon NJ Health clinical team will review cases to determine if the readmission:

  • Is medically necessary based on a change in clinical condition.
  • Was the result of early discharge of an unstable patient.
  • Attributed to a lack of coordinated discharge planning and/or inadequate transition of care between an acute care facility to the next setting of care (i.e., home, assisted living, skilled nursing facility, etc.
  • Was attributed to the absence of care and services that should have been rendered in the previous inpatient hospital stay.

Q4. When will this policy go into effect?

A4. This policy will go into effect January 1, 2018.

Q5. How will the policy be enforced?

A5. Horizon NJ Health knows that in order for us to collectively promote the quality of care and service for our members, we need to maintain our strong partnership with our Providers. As such, Horizon NJ Health will utilize the month of January for our clinical teams, Medical Directors and Care Managers to provide real-time feedback on cases that would be considered as inappropriate readmissions pursuant to the policy. Beginning February 1, 2018, the policy will be enforced. Horizon NJ Health will also conduct educational sessions in January with Providers and their utilization and care management teams. Horizon NJ Health is working with the NJ Hospital Association to hold Discharge Planning Summits next year, where hospital and Horizon NJ Health clinical teams come together to discuss best practices in effective discharge planning.

Q6. Is there an existing policy upon which this new Readmission Policy is based?

A6. This is a new medical policy based on Centers for Medicare & Medicaid Services (CMS) guidance as part of its Quality Improvement Organization (QIO) Program.

Q7. What financial impact will this new policy have on members?

A7. There will be no direct financial impact to members. Members will not be charged for hospital readmissions; providers may not balance bill members or charge them for services rendered.

Q8. Does this new policy apply to psychiatric or substance use disorder readmissions?

A8. No, the policy does not apply to psychiatric or substance use disorder readmissions.

Q9. Does the policy cover readmissions to ANY hospital or only to the SAME hospital within 30 calendar days?

A9. The policy applies to readmissions to the SAME hospital within 30 calendar days.

Q10. Will the adverse determination (denial) happen first and the clinical review happen after the denial is issued? Will the clinical review for readmissions be prospective, concurrent or retrospective? How does the review process work?

A10. An adverse determination (denial) will be issued by the medical director after the clinical review.

Here is an example:

In the scenario of a potential readmission, the Horizon NJ Health utilization review nurse receives a notice of admission (NOA) from a hospital. The nurse reviews the care management system to determine if there was a previous inpatient hospital stay at the same hospital within the last 30 days and identifies the admitting diagnosis.

The nurse prepares the case and then refers it to a Horizon NJ Health medical director for clinical review. The referred case will highlight the dates of the previous admission to the same hospital within the last 30 days, admitting diagnosis and includes relevant clinical information provided by the hospital.

The medical director reviews the case focusing on admitting diagnosis, the clinical information provided, and the previous hospitalization, discharge planning and diagnosis. The medical director will attempt to contact the admitting physician or physician advisor to offer a peer-2-peer (P2P), also known as a reconsideration discussion. If contact was unsuccessful, a voice message will be left. If the P2P discussion does not result in a change in the clinical assessment, the medical director will issue an adverse determination (denial) referencing the 30-day Readmission Policy.

An adverse determination letter including an explanation of the rationale for the determination will be sent via mail to the member and provider (n.b., members are held harmless); at the same time a facsimile is transmitted to the admitting physician/hospital office. In all instances, the medical director’s contact information is provided. Note, the hospital physician can request a P2P for up to three (3) business days from the date of the facsimile transmission.

If the P2P discussion does not result in a change in the clinical determination, the provider may appeal the decision to provide additional clinical information. The adverse determination letter will outline the member’s appeal rights and the appeal process.

Q11. Can Horizon NJ Health assist with discharge planning?

A11. Yes, Horizon NJ Health Care Managers can coordinate with the facility and patient to improve the transition of care and follow up with primary care providers. Care managers will coordinate with the facility on medication reconciliation, needed DME and primary care physician follow up.

Q12. Is there any additional information that can provide assistance with the development of strategies to reduce readmissions for the Medicaid population?

A12. The Readmission Policy was created in recognition of the continued national attention on reducing inappropriate readmissions to improve the quality of care. The website below will direct you to a toolkit specific to Medicaid readmissions developed by the Agency for Healthcare Research and Quality (AHRQ). It provides helpful information on transitional care needs and has been field tested nationally by individual hospitals and groups of hospitals through quality improvement programs.

Q13. Who should I contact if I have more questions about the 30-day Readmission Policy?

A13. Please call our Clinical Inquiries line at 1-609-537-2450.