Effective January 1, 2023, Patrius Health adopted a 30-day Readmission Review Policy for Blue Advantage^® members. We will review all readmissions to the same acute care facility within 30 days of discharge. If a readmission is determined to be inappropriate or preventable, the stay will be considered part of the initial admission. See our program FAQs for more information.

Exclusions from the Readmission Review Program:

• Transfers from out-of-network to network facilities
• Transfers of patients to receive care not available at the first facility
• Planned readmission for repetitive or staged treatments (e.g., cancer treatments)
• Admissions associated with malignancies, burns, transplants or cystic fibrosis
• Anchor admission with a discharge status of “left against medical advice”
• Obstetrical and newborn admissions
• Anchor admissions filed as behavioral health
• Readmissions 31 days or more from the date of discharge from the anchor admission

A readmission within 30 days of the first admission is considered inappropriate or preventable under the following circumstances and will be considered part of the initial admission:

• Prior premature discharge from the same hospital
• Circumvention of the contracted rate by the hospital
• Complication of care

In addition, in accordance with CMS guidance, Patrius Health has an expectation of thorough and appropriate discharge planning. Therefore, readmissions for the following reasons are considered preventable:

• Failure to have an appropriate discharge plan
• Failure to have proper coordination between healthcare teams directly attributable to actions of the hospital

The readmission review will consider the impact of patient noncompliance based on the following documentation:

• A follow-up appointment with the primary care physician or specialist within, preferably, seven days but no later than 30 days of discharge, including the physician’s name, and the date and time of the appointment
• Medication reconciliation including changes to pre-admission medications
• Efforts to determine continued availability of needed medications for all conditions addressed during the hospitalization
• Education on signs, symptoms and action plans for any post-discharge events
• Efforts made to identify solutions to barriers of social determinants of health