We’re simplifying our related hospital admissions payment policy

What’s happening?

As of Dec. 1, 2024, changes to streamline our hospital readmissions payment policy will take effect:

• “Higher of” DRG payment policy for all related admissions: When admissions within 30 days meet related admission criteria, we’ll pay the claim with the higher diagnosis-related group (DRG) relative weight. The other claim that is not reimbursed will be denied. Your Geisinger Health Plan patients should not be billed for costs associated with the unpaid claim.
• Prior authorization and claims appeal processes remain unchanged: Geisinger Health Plan Medical Management will continue to identify potential related readmissions, notify hospital providers and facilitate discussions with medical directors when appropriate. Your rights to dispute and appeal claims denials as a Geisinger Health Plan participating provider also remain unchanged.
• Plans affected: The new readmissions payment policy will apply to these plans as of Dec. 1 — Geisinger Gold plans, Geisinger Health Plan commercial and Marketplace plans, and plans for which Geisinger Health Plan is the third-party administrator (except Geisinger employee TPA plans).
• GHP Family and GHP Kids will continue to follow existing related admissions policy until further notice: We pursue policy continuity among all our plans to the extent we can. However, this policy change will not take effect for GHP Family (Medicaid) and GHP Kids (CHIP) plans until further notice.

Related admission criteria

• Both admissions must occur at the same facility.
• Conditions or procedures are the same or closely related to those recorded during the prior discharge.
• An infection or other complication of care.
• A condition or procedure indicative of a failed surgical intervention.
• An acute decompensation of a coexisting chronic disease.
• A need that could have reasonably been prevented by the provision of appropriate care consistent with accepted standards in the prior discharge or during the post discharge follow-up period.
• An issue caused by a premature discharge from the same facility.
• A reason that is medically unnecessary.

Exclusion criteria

Readmissions within 30 days of a previous admission are reviewed as potentially related unless the initial or subsequent admission is one of the following excluded types of admissions, as recognized by the National Committee for Quality Assurance:

• Skilled nursing admissions
• Inpatient rehabilitation admissions
• Readmissions for mental health or substance use disorders
• Planned admissions, including those for staged or serial treatments (e.g., chemotherapy)
• Readmissions where the anchor admission had a discharge status of “Left Against Medical Advice”
• Transplant services

Timing of policy changes

For Geisinger Gold, Geisinger Health Plan commercial, Marketplace and TPA plans: The new process will only apply to readmission scenarios where the initial admission occurs on or after Dec. 1. This means that admission claims in the first week of December 2024 may still be subject to the old process if the initial admission occurred in November 2024.

Questions

Questions about Geisinger Health Plan’s related hospital admission payment policy? Contact our Provider Care Team: 844-GHP-PROV (844-447-7768).

This Operations Bulletin and the information contained herein amend the GHP Participating Provider Guide, effective Dec. 1, 2024.