Compliance and Readmissions

Managing hospital readmissions is one of the biggest challenges facing healthcare today. Many hospitals are experiencing a reduction in Medicare payments this fiscal year for having excess readmissions for acute myocardial infarction, heart failure, and pneumonia.

The report by the Dartmouth Atlas Project, published by the Robert Wood Johnson Foundation and posted online February 11, 2013, states that “one in eight Medicare patients were readmitted to the hospital within 30 days of being released after surgery in 2010, while one in six patients returned to the hospital within a month of leaving the hospital after receiving medical care.”  

Traditionally, compliance reviews inpatient discharges for appropriate coding and billing, not for readmissions. You know that compliance should, at a minimum, have a good understanding of readmissions in order to determine if it is an area that needs a compliance review.

Where to begin to assess if there is a readmissions risk at your hospital?

One question should immediately come to mind, “What is the exact amount of Medicare payment reduction for my hospital?” If, in response, your hospital’s finance department provides you with an annualized dollar amount of the reduction of Medicare payments, then you know your hospital has some risk.

Your next question should be, “Who do I need to talk to in order to understand the scope of the risk?” As a compliance leader, you need to understand which hospital operations impact readmissions and the data available that measure your hospital’s readmission rates. Understanding the people, processes and technologies behind how readmission rates are calculated will help you assess the risk.

Introduce yourself to the Utilization Review/Case Management team for your hospital. Learn how they coordinate and plan for a patient’s discharge. You may be amazed to find out just how many phone calls they have to make to help the patient move to the next level of care – even if it is just to visit their primary care physician two weeks after being discharged home.

Talk with Medical Records and ask what is the deficiency rate for discharge summaries by attending physician one day, seven days and one month after discharge. You may be surprised at how many discharge summaries are not completed in a timely fashion. If your hospital has an electronic health record system, review the electronic standard format of the discharge summary to determine if it meets all of the Conditions of Participation requirements of a complete discharge summary.

Review the available data for your hospital, including the PEPPER report’s readmission graphs (there are two set of graphs and data tables). Talk with the analyst who gathers, analyzes and posts the data reported for the Hospital Inpatient Quality Report Program. This data, along with discharge claims data, feeds into the Hospital Readmissions Reduction Program Hospital Specific Report and the Hospital Compare website. Check out the and Hospital Compare websites to learn more about the data analysis and the calculations used. Lastly, learn how the Final Readmissions Adjustment Factor and Excess Readmission Ratio were calculated and the dollar amount the Medicare payment was reduced for your hospital.

Once you have explored these areas and have a good understanding, you will be able to successfully measure the level of readmissions risk at your hospital. 


 The Revolving Door: A Report on U.S. Hospital Readmissions.

 by Harriet Kinney, GRC Advisory Board Member