Q&A: 30-day readmission denial appeals

Q: Do you appeal many 30-day readmission denials and what is your approach?

A: We appeal readmission denials as these speak to quality of care and we have a vendor who assists. Other departments and initiatives look at readmission from their standpoints although they are not involved in appeals, but it is good to identify those initiatives for any collaborative opportunities. 

My approach has multiple steps, including:

• Review both the index admission and the subsequent admission for similarities and differences.
• Examine the payer policy for a related admission. Know their definitions and exclusions.
• Review all interim documentation. Use outpatient follow-up as support for coordination of care provided to prevent a readmission.
• Remember, related admissions were originally designed to identify quality of care issues, most notably early discharge. Try to make it clear that early discharge did not play a role in a readmission. 
• Many complications or exacerbations will occur simply due to the nature of the disease process despite your great care measures to prevent them. Identify all these and highlight those measures. 
• Measure the strength of your position. If you feel strongly that the two admissions are not related for all reasons stated above, be sure to go through all appeal options available to you including involvement of upper management.
• Know who is reviewing your appeal. You want the payer or insurance company to have final say in the appeal decision if you feel your position warrants it. If you have a consultant/vendor helping you with appeals, understand that they may not be aware of the relationship between the facility and the payer.  

Editor’s note: Angela Geiger, BSN, RN, CCS, CPC, COC, answered this question as part of a recent ACDIS Central Pennsylvania Chapter meeting. Contact her at ageiger@pennstatehealth.psu.edu.