Medicare Hospital Readmissions: Laws to Raise Patient Care

Returning to the hospital shortly after discharge can be frustrating, expensive, and frightening. The readmission could also signal that something went wrong with your initial treatment. Understanding readmission health policy can help ensure you receive better quality of care. It can also help avoid unnecessary return visits.

If you believe you received poor hospital care that led to readmission, you can contact a healthcare attorney. They can protect your rights and evaluate your legal options.

What Medicare Considers as Hospital Readmission

A hospital readmission occurs when you are admitted again as an inpatient within 30 days of being discharged from a previous hospital stay. Medicare tracks these readmissions because they often indicate problems with your initial treatment. Here’s what qualifies as readmission under Medicare’s guidelines:

• An unplanned inpatient admission that happens within 30 days of discharge from the first hospital stay
• The return admission may be to the same hospital or to another applicable acute-care hospital
• Your readmission diagnosis can be unrelated to your initial hospitalization
• Only applies to applicable acute care hospitals participating in the program

The program excludes planned returns from counting as readmission. A patient returning for a scheduled procedure, surgery, or a follow-up check-up is not considered a readmission. Not all conditions qualify for readmission penalties.

The Department of Health and Human Services decides which conditions fall under the HRRP. They exercise this authority through the Centers for Medicare & Medicaid Services (CMS). At present, CMS tracks six conditions under the program:

• Heart attack (acute myocardial infarction)
• Heart failure
• Pneumonia
• Chronic lung disease (COPD)
• Coronary artery bypass graft (CABG) surgery
• Elective hip or knee replacement (THA/TKA)

CMS currently uses a rolling three-year data window. However, CMS has finalized changes to shorten this to two years beginning with FY 2027.

How Are Unnecessary Hospital Admissions Identified?

Medicare uses certain methods to identify patterns of hospital readmission. The following are some of the determinants used by the CMS to check hospital readmission:

Comparing Hospital Performance

Medicare calculates a hospital’s performance by counting the number of patients who return within a set time. Since 2019, Medicare has started grouping hospitals with the same patient population together before comparing them. This ensures that health systems with low-income patients are not unfairly penalized.

Excess Readmission Ratio (ERR)

CMS measures hospital performance through the Excess Readmission Ratio (ERR). The ERR is the ratio of actual to expected unplanned readmissions for each condition. This risk-adjusted ratio is one of the key readmission measures used to decide whether a hospital faces a payment penalty.

Based on the analyzed data, hospitals that performed worse than others in their peer group could face Medicare payment cuts. CMS uses a specific penalty indicator. Hospitals face payment cuts if their ERR exceeds CMS benchmarks for covered conditions.

What Are Hospitals Doing to Reduce the Rate of Readmissions?

Hospitals have numerous incentives try to minimize readmissions, not the least of which is to avoid facing potential penalties. Here are some of the methods being employed to reduce readmissions:

Discharge Planning Conditions of Participation

Hospitals certified under Medicare must maintain a legally compliant discharge planning process. They must check the patient’s needs, work with follow-up healthcare providers, and give patients clear comparisons of nursing facilities, rehab centers, or long-term care. 

The program imposed these duties on hospitals to lower the rate of readmission. It does this by ensuring safe and informed care transitions. They should also coordinate patients with appropriate care facilities for post-discharge support.

Standardized Post-Acute Care Data Reporting

Medicare requires certain post-acute care providers, such as skilled nursing facilities and home health agencies, to submit standardized quality data to CMS. This is used to track preventable readmissions.

These reports show preventable hospital readmissions. The data is adjusted based on how risky each readmitted patient’s condition was. This makes it possible to compare performance fairly across different types of facilities. Hospitals and healthcare providers then use these metrics to improve discharge planning and care coordination. The goal is to reduce the 30-day readmission rates.

CMS Annual Rulemaking and Guidance

Every year, CMS issues final rules under the Inpatient Prospective Payment System. These rules update the readmissions program and refine which conditions are measured. They also clarify hospital obligations under the discharge planning requirements. 

The Medicare Payment Advisory Commission (MedPAC) provides Congress with recommended policies to ensure improved quality of hospital care. Hospitals try to comply with the latest rules to avoid facing financial penalties.

What Patients Can Do if Their Rights Are Violated

Federal law gives Medicare patients clear ways to protect themselves. Medicare beneficiaries who believe their rights were violated can take action in the following ways:

Appeal a Premature Discharge

If you think the hospital discharged you too early, you have the right to ask for an expedited review. This review is conducted by a Quality Improvement Organization (QIO). To ensure patients know about this right, the program requires hospitals to give every patient the Important Message from Medicare (IM) upon admission and again before discharge. If the patient disagrees with the message, the hospital has to provide a Detailed Notice of Discharge. This notice must state the medical reasons for release.

For expedited discharge appeals, the QIO reviews the case promptly, usually within one to two business days. The hospital must delay discharge until the review decision is made.

File a Complaint Against the Hospital

The program requires hospitals to have a safe discharge planning process that meets federal standards. Patients can complain if the hospital does not properly check them before sending them home. They can contact either the CMS or the State Survey Agency that inspects hospitals. 

Federal law also requires hospitals to inform patients of their appeal rights and assist them in filing complaints. Complaints can trigger compliance investigations and potential penalties against the hospital.

Challenge Coverage Decisions in Medicare Advantage

Patients enrolled in Medicare Advantage plans have parallel rights when a plan or hospital tries to end inpatient care. They may request immediate review by a QIO. The plan must provide written notice of the decision and explain how to appeal. The QIO has to issue a decision quickly to ensure that enrollees are not left without coverage during a dispute.

Demand Transparency on Observation Status

If the hospital sent you home and you had to return, the hospital might place you under observation instead of admitting you. In this case, the hospital should give you a Medicare Outpatient Observation Notice (MOON). This applies if you remain in observation for more than 24 hours. By law, the hospital has to provide the notice within 36 hours of observation services beginning or sooner before discharge, whichever occurs first.

The MOON explains how observation status affects costs and eligibility for post-hospital benefits. If the hospital does not deliver this notice on time, it’s a violation that you can report to CMS.

Seek Legal Recourse

Poor hospital care or unsafe discharge practices can harm patients and result in hospital readmission. When this happens, patients may pursue state malpractice or negligence claims if substandard care caused harm. These are handled separately from Medicare’s enforcement processes.

Patients may also take action if a hospital or plan violates federally protected rights. Examples include failing to give required notices or mishandling discharge planning. In these cases, patients should contact a healthcare attorney to examine your readmission. They can help file claims to enforce compliance when hospitals break the law.

Seek Legal Advice From a Healthcare Attorney

Hospital readmissions can cause stress, extra costs, and health risks for patients. HRRP aims to hold hospitals responsible for too many readmissions. The initiative of the program is to push hospitals to improve discharge planning, follow-up care, and patient safety. If you experienced a readmission due to the fault of the hospital, consult a healthcare attorney. They can evaluate your case and help you understand your legal options to see accountability.