From The Appeals Desk: The “30 Day Readmission” Denial

Insurance company denials are terribly frustrating. They delay prompt processing of claims. They require annoying extra steps to get paid. And, frequently, they require spending more money on denial and appeal experts such as myself to help fight them. Yes, I’m grateful for the business, and I share the frustration of hospitals and health systems all the same.

In previous articles, we have been discussing the various different types of reasons insurance companies deny payment for services rendered by hospitals to their patients. Perhaps the most annoying and frustrating for me is the “30 day readmission” denial. This is a denial in which payment is denied for a hospital stay that is within 30 days of a previous hospital stay. The allegation is that the patient was inappropriately discharged from the previous hospital stay, and thus the subsequent stay should be considered part and parcel of the first, what we call the “index,” hospitalization. I have seen these denials come through even with hospital stays three weeks later, even for a different reason. 

Now, the Centers for Medicare and Medicaid Services, affectionately known as CMS, also penalizes hospitals for excess readmissions within 30 days. It is called the Hospital Readmission Reduction Program, and it tracks the ratio of the predicted-to-expected readmissions to the hospital for the following conditions: (1) acute myocardial infarction, (2) chronic obstructive pulmonary disease, (3) acute heart failure, (4) pneumonia, (5) coronary artery bypass graft, and (6) elective total hip and knee surgery. If there are excessive readmissions to the hospital for patients with any of these conditions, payments to that hospital are reduced the following year. 

Some commercial insurance companies have taken the concept of this program to the extreme by denying payments for any hospitalization, for any reason, for any condition within 30 days. For example, if a patient is admitted to the hospital for pneumonia, and then suffers a heart attack three weeks later and admitted again for the heart attack, I have seen commercial insurance companies deny payment for that subsequent hospital stay, even though it had nothing to do with the previous one.

CMS claims this program “encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions.” This goal, of course, is laudable. Everyone wants the best quality care if they must be admitted to the hospital.

At the same time, a readmission to the hospital is completely unavoidable. Sometimes, as I mentioned previously, a patient suffers an unexpected complication such as a cardiac arrest. Sometimes, a patient is in a car accident and has to be admitted to the hospital. Sometimes, a patient does not follow medical instructions, such as taking diuretics to reduce total body volume for heart failure, and they present back to the hospital for another exacerbation of heart failure. Sometimes, it is unfair to penalize a hospital for something that is beyond its control.

At least, CMS tracks a ratio rather than an absolute number. The denials I am talking about here are absolute: a payer will simply deny payment because a patient is admitted to the hospital within 30 days. Even if it is 29 days, I have seen these denials come through. And, frequently, there’s absolutely no explanation as to why the denial occurred. 

Moreover, many times, the subsequent hospitalization is very long because the patient is extremely sick, such as suffering cardiac arrest and having brain injury due to lack of oxygen. To simply deny the subsequent hospital stay because it happened to occur within 30 days of a previous hospital stay is inappropriate and beyond frustrating. “Ensuring quality of care” by by making such a denial is disingenuous at best. 

It is one thing if a hospital, seeking to minimize length of stay, prematurely discharges a patient while they are still clinically unstable: for example, with an incompletely treated infection or still with significant heart failure. That hospital deserves to be penalized for a readmission. I can say, with a reasonable amount of certainty, that most hospitals do not fall into this category. 

Most hospitals try their best to treat the patients entrusted to their care in the most appropriate and efficient manner as possible. I can understand CMS’ readmission reduction program. The readmission denials I see coming from commercial payers are simply punitive and wholly unnecessary. 

It is unlikely that these types of denials will ever go away completely, especially given the presence of the CMS hospital readmissions reduction program. I can always see commercial payers pointing to the program as inspiration for their own 30 day readmission denials. At the same time, I am going to call out their callous and arbitrary nature. With all the challenges and challenging environments we in healthcare have to deal, needing to expend precious resources to defend denials such as these is truly baffling.