According to Medicare, a hospital readmission is "an admission to an acute care hospital within 30 days of discharge from the same or another acute care hospital." However, a readmittance for follow-up care does not constitute a "readmission" for Medicare. The Hospital Readmission
Hospital readmission
A hospital readmission is an episode when a patient who had been discharged from a hospital is admitted again within a specified time interval. Readmission rates have increasingly been used as an outcome measure in health services research and as a quality benchmark for health systems. Hospital readmission rates were formally included in reimbursement decisions for the Centers for Me…
How long can you stay in the hospital under Medicare?
The 3-day rule for Medicare requires that you are admitted to the hospital as an inpatient for at least 3 days for rehab in a skilled nursing facility to be covered. You must be officially admitted to the hospital by a doctor’s order to even be considered an inpatient, so watch out for this rule.
What is the Medicare 3 day hospital stay rule?
meet the 3-day rule 3-DAY PRIOR HOSPITALIZATION BEFORE SNF ADMISSION Medicare beneficiaries meet the 3-day rule by staying 3 consecutive days in one or more hospitals as an inpatient. Hospitals count the admission day but not the discharge day. Time spent in the ER or in outpatient observation prior to admission does not count toward the 3-day rule. 3-DAY RULE WAIVER
Can hospitals break even with Medicare?
There are things hospitals can do to break even or even make a profit from Medicare.For one, they can introduce programs that would reduce the number of patients who become “outliers” because they suffer complications from surgical infection, hospital acquired pneumonia, falls, mistakes, and so on.
Does Medicare pay for rehab after hospital stay?
You pay a per-day charge set by Medicare for days 21–100 in a benefit period. You pay 100 percent of the cost for day 101 and beyond in a benefit period. Medicare covers inpatient rehab in a skilled nursing facility after a qualifying hospital stay that meets the 3-day rule.
What is the Medicare readmission policy?
Policy statement Readmissions occurring within 2 – 30 days will be subject to clinical reviews. If the clinical review indicates that the readmission is for the same or similar condition, it may be considered a continuation of the initial admission for the purposes of reimbursement.
At what level of readmission rates are hospitals penalized?
The Affordable Care Act (ACA) established the Hospital Readmission Reduction Program (HRRP) in 2012. Under this program, hospitals are financially penalized if they have higher than expected risk-standardized 30-day readmission rates for acute myocardial infarction, heart failure, and pneumonia.
How do you stop a 30-day readmission?
Studies have shown that education and reinforcement are pivotal in reducing HF readmissions [10]. Early follow-up visits with a cardiologist or PCP within seven days of discharge after an HF hospitalization have also been shown to help reduce the 30-day readmission rate [9].
What is a readmission policy?
Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program. A readmission is defined as an admission to a hospital within 30 days of a discharge from the same or a similar hospital.
Does Medicare penalize hospitals for readmissions?
In fiscal year 2022, CMS will penalize 2,499 hospitals for having too many Medicare patients readmitted within 30 days, according to federal data analyzed by Kaiser Health News.
What counts as a hospital readmission?
CMS defines a hospital readmission as "an admission to an acute care hospital within 30 days of discharge from the same or another acute care hospital." It uses an "all-cause" definition, meaning that the cause of the readmission does not need to be related to the cause of the initial hospitalization.
Does Medicare pay for readmission within 30 days?
Medicare counts the readmission of patients who returned to a hospital within 30 days even if that hospital is not the one that originally treated them. In those cases, the penalty is applied to the first hospital.
What is an avoidable readmission?
A Potentially Preventable Readmission (PPR) is a readmission (return hospitalization) to an acute care hospital following a prior acute care admission within a specified time interval, for a reason that is clinically related to the initial hospitalization.
How do you address a hospital readmission?
What are ways to reduce hospital readmissions?Use admission, discharge, transfer (ADT) data for proper transition of care. ... Follow up with patients after discharge. ... Identify risk factors for readmission using EHR data. ... Support patient medication adherence to prevent rehospitalization.More items...•
Why are patients readmitted to hospitals?
Early discharge, inadequate communication during discharge, and poor coordination of care can lead to hospital readmission. Think about leaving the hospital with a stack of papers and a head full of information from all different providers.
How many readmissions occur within 90 days of discharge from hospitals?
Condition-specific 30- and 90-day readmission rates by post-acute discharge setting are presented in Table 1. For patients with stroke, 30-day readmission rates ranged from 8.8% in HHAs (ischemic) to 14.4% in SNFs (hemorrhagic) and 90-day rates ranged from 18.2% in HHAs (ischemic) to 26.1% in SNFs (hemorrhagic).
What are the effects of hospital readmissions?
For instance, in-hospital mortality has been found to be higher for patients who are readmitted versus those who are not. Other researchers argue that readmissions lead to an increased length of stay and expenditure of more hospital resources.
How long does it take for an unplanned readmission to happen?
Unplanned readmissions that happen within 30 days of discharge from the index (i.e., initial) admission. Patients who are readmitted to the same hospital, or another applicable acute care hospital for any reason. Readmissions to any applicable acute care hospital are counted, no matter what the principal diagnosis was.
What is HRRP in healthcare?
HRRP is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions . Section 3025 of the Affordable Care Act required the Secretary of the Department of Health and Human Services ...
What is the Medicare readmission penalty for 2020?
The 2020 Medicare Readmission Penalty Program. Each year, Medicare analyzes the readmission rate for every hospital in the United States and then imposes financial penalties on those hospitals determined to have excessively high readmission rates. And every year, most U.S. hospitals get penalized. This year is no exception – 83% ...
What is readmission reduction?
The hospital readmission reduction program was created as a part of the Affordable Care Act as a way to improve quality of care and reduce overall Medicare costs. Readmissions are defined as a patient being readmitted to any hospital and for any reason within 30 days of discharge from the hospital being analyzed.
What is the Medicare quintile?
Medicare divided all U.S. hospitals into quintiles based on the percentage of dual eligible patients. Hospitals were only compared to other hospitals within the same quintile for the purposes of penalty calculation; therefore, a hospital with a high percentage of dual eligible patients was held to a different readmission rate expectation ...
Why are hospitals financially incentivized to discharge patients?
Since hospitals are paid by the DRG (in other words, by the diagnosis), hospitals are financially incentivized to discharge patients as quickly as possible in order to reduce their expenses. The Medicare hospital readmission reduction program was designed to offset that financial incentive by penalizing hospitals that discharge patients prematurely.
How does Medicare respond to the penalty based on a given hospital’s patient demographics?
Medicare responded by making 2 adjustments to the penalty based on a given hospital’s patient demographics: The severity of illness of the hospital’s patients (often called the case mix index) with the premise that the sicker a patient is, the more likely that patient is to be readmitted to the hospital. The rate of “dual eligible” patients, that ...
Is the readmission penalty fair?
Overall, the current readmission penalty program appears to be more fair to hospitals that care for socioeconomically disadvantaged patients. However, the danger remains that by creating a barrier for hospitals to readmit patients who truly need to be readmitted, outpatient mortality can increase. November 17, 2019.
What is excess readmission ratio?
The excess readmission ratio includes adjustments for clinical factors such as patient demographic attributes, comorbidities, and patient “frailty.”. Hospitals are compared with a national average readmission ratio that generally applies to a hospital’s patient population and the applicable condition.
What is readmission reduction?
It is meant to help ensure that hospitals discharge patients when they are fully prepared and safe for continued care at home or at a lower acuity setting. The Affordable Care Act of 2010 requires HHS (Department of Health and Human Services) to establish a readmission reduction program.
What is the Affordable Care Act?
Recommendations. Answer. The Affordable Care Act of 2010 requires HHS (Department of Health and Human Services) to establish a readmission reduction program. This program, effective October 1, 2012, was designed to provide incentives for hospitals to implement strategies to reduce the number of costly and unnecessary hospital readmissions.
How Medicare works to keep you out of the hospital
Tanya Feke, MD, is a board-certified family physician, patient advocate and best-selling author of "Medicare Essentials: A Physician Insider Explains the Fine Print."
What Is a Readmission?
Staying overnight in a hospital does not necessarily mean you were admitted to the hospital. The word “admission” refers to a hospital stay when your doctor puts an inpatient order on your medical chart. When you are placed under observation instead, you continue to receive care in the hospital but you have not been admitted.
Preventable Hospital Readmissions
When someone returns to the hospital within a short period of time, especially if it is for the same problem, it raises questions. Did they receive quality care while they were in the hospital? Were they discharged from the hospital too early? Did they receive adequate follow-up when they left the hospital?
The Hospital Readmissions Reduction Program
In 2007, the Medicare Payment Advisory Commission estimated that potentially avoidable readmissions cost Medicare $12 billion every year. 4 The Hospital Readmission Reduction Program (HRRP) was created as a way to reduce those costs.
Medical Conditions to Watch For
Not all readmissions are penalized by the Hospital Readmission Reduction Program. Medicare only looks at readmissions that happen after an initial admission for the following medical conditions and surgeries:
Results of the HRRP
The Hospital Readmissions Reduction Program has proven beneficial for at-risk populations. This includes people with low incomes, people who go to hospitals that have a high proportion of low income or Medicaid patients, and people with multiple chronic conditions.
Controversy Over the HRRP
The Hospital Readmissions Reduction Program decreased readmissions, but questions remain as to whether that has actually improved patient outcomes.
