From The Appeals Desk: Readmission Denials Can Be Annoying

One health care system is suing because of it. Yet, there should be a better way

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Photo by Anna Sullivan on Unsplash

Of all the appeal letters I write for hospital partners, the ones that annoy me the most are the ones appealing “30 Day Readmission” denials. Basically, some insurers will deny payment for a hospital stay that has occurred within 30 days of a previous hospital stay and will tell the hospital, in essence, “We paid you for the previous hospital stay, and since this new stay is related to that one, we won’t pay you any more.

It seems very arbitrary. What if the subsequent admission could not be prevented? What if something else happened that required admission to the hospital again? Some chronic conditions are so crippling that multiple hospital admissions are typical. This policy of denying an admission within 30 days of a previous one seems punitive.

Well, one hospital system in Florida is now suing Aetna over its readmission policy:

Lakeland Regional Health is suing the Aetna for more than $1 million claiming the health insurer has “arbitrarily” denied paying for patients’ medical treatment.

Lakeland Regional filed the lawsuit against Aetna Health in January, asserting the company’s refusal to reimburse the hospital for health care services it provides has caused financial damage and constitutes a breach of contract. Aetna has moved to have the lawsuit dismissed.

Lakeland Regional takes issue at the health insurer’s Readmission Payment Policy, which sets rules for how much it will pay for an individual’s second hospital visit for a medical issue within 30 days. The hospital claims many of its bills for readmission are being denied.

“Many of the readmissions which have been denied by Aetna are patients who are chronically ill with many comorbidities,” reads Lakeland’s complaint. “As such, the cases are complex and cannot be cavalierly denied as Aetna has done under the guise of its policy.”

On April 26, Aetna’s lawyers moved to have the lawsuit dismissed, writing in their response:

The readmissions policy is designed to prevent a facility, like Lakeland, from failing to provide appropriate and complete care as part of an initial hospital admission. If the conditions had been properly treated as part of the initial admission, the second admission would not be necessary.

The thing is, frequently, the second admission absolutely cannot be avoided, and I see this in most — if not all — of the cases I appeal for a readmission within 30 days.

For example, say a patient has end-stage COPD. He is on continuous oxygen 24 hours a day. He is very debilitated due to the lung disease. He gets admitted to the hospital for an exacerbation of the COPD, gets treated appropriately, greatly improves, and is discharged home after 5 days.

Three weeks later, he catches the flu — even though he had the flu shot — and gets admitted back to the hospital for an exacerbation of his end-stage COPD secondary to acute influenza infection. He gets treated appropriately and is discharged after 5 days. Not uncommonly, this second hospital stay will get denied because it was “within 30 days of the previous admission for acute exacerbation of COPD.”

Why? He was appropriately treated and was appropriately discharged the first time, and beyond his control, he catches the flu and has to get admitted back to the hospital. Multiple admissions to the hospital are not uncommon with patients who have severe lung disease. Why penalize the hospital with nonpayment for a hospital admission that was, yes, technically within 30 days, but could not have been foreseen or prevented?

And so, I see from where the frustration of Lakeland Regional Health comes leading to the lawsuit. The process of appealing these denials can be long and costly, and it places great strain on hospitals and hospital systems that are already strained from decreasing reimbursements and increased costs.

At the same time, I can understand how an insurer would want to make sure that their members are receiving the best and most efficient care possible, and if care is substandard, then the healthcare providers should be held to account. The tension between these two positions is perpetual, and it is very easy how it can lead to a lawsuit.

There should be a better way. Although it would take a lot of time and effort — and cooperation among hospitals, physicians, advanced practice providers, and insurers — I can envision a Peer-to-Peer process in the event of a hospital stay that occurs within 30 days of a previous stay.

In this process, either the Attending Physician (ideally) or a Physician Advisor can have a live conversation with the insurance Medical Director and discuss the particulars of a hospital stay that occurs within 30 days of a previous admission. They can, together, determine if the second hospital stay was preventable or not preventable, and the Medical Director can make a determination.

This seems much better, more proactive, and less arbitrary than having to appeal a 30-day readmission denial after the fact. And if the Peer-to-Peer discussion is done right, it can lead to better care for the patient which, after all, is what all of us — providers and insurers alike — are in the business of healthcare to ensure.

NY Times featured Pulmonary and Critical Care Specialist | Physician Leader | Author and Blogger | His latest book is “Code Blue,” a medical thriller.

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