Case Management

Dispute inappropriately denied readmissions

Case Management Monthly, October 1, 2010

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Several case managers have recently received readmission denial letters from their regions’ Medicare Advantage (MA) plan that have them confused.  

The case managers are not surprised that their hospitals were audited; CMS has identified reducing preventable readmissions as a priority in reducing healthcare costs. They are surprised because the readmissions in question were actually appropriate and medically necessary. 

Several case managers shared their denial stories on the American Case Management Association’s (ACMA) listserv. In most cases, MA plans cite Medicare Claims Manual, Chapter 3, Section 40.2.5 as the basis for the denials. 

According to one case manager from South Carolina, the denial letter said the MA plan audited cases where patients were readmitted within 72 hours for a condition related to the first admission. The letter also referenced Section 40.2.5 but didn’t cite a specific passage. 

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