Effective January 1, 2025, Patrius Health will update the Readmission Review Policy for Blue Advantage® members to align with CMS’ Readmission Review Standards. All readmissions to the same acute care facility within 30 days of discharge will be reviewed.

If a readmission is determined to be inappropriate or preventable, the stay will be considered part of the initial admission.                                                                                                                
Exclusions from the Readmission Review Program include:

• Transfers from out-of-network to in-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

Readmission review involves admissions to an acute, general or short-term hospital occurring less than 31 calendar days from the date of discharge from the same general short-term hospital.                                                                                                                                               
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:

• Premature discharge of patient that results in subsequent readmission of patient to same hospital: 
  • Occurs when a patient is discharged even though he/she should have remained in the hospital for further testing, monitoring or treatment, or was not medically stable at the time of discharge.
• Readmission of patient to hospital for care that could have been provided during first admission:
  • Occurs when a patient is readmitted to a hospital for care that, pursuant to professionally recognized standards of healthcare, could have been provided during the first admission. This action does not include circumstances in which it is not medically appropriate to provide the care during the first admission.