New Audit Focuses on Related Inpatient Readmissions of Medicare Members


Effective April 18, Humana began auditing acute inpatient hospital readmissions of Medicare members.

Inpatient readmissions will be reviewed by a clinical audit to determine if readmission was preventable and related to a previous inpatient admission. If the readmission is deemed preventable and related, it will not be covered. This review is consistent with section 40.2.5 of Chapter 3 of the Medicare Claims Processing Manual and sections 4240 and 4250 of Chapter 4 of CMS’ Quality Improvement Organization Manual.

The following are examples of preventable readmissions. This is not an all-inclusive list.

  • A premature discharge that resulted in a readmission to the same hospital.
  • Care during the second admission that should have occurred during the first admission. Humana uses CMS guidelines to make these determinations.
  • An attempt to circumvent appropriate Inpatient Prospective Payment System (IPPS) payment.

The audit will be completed after payment.

Notification of this change was posted Jan. 16, 2016, on the Claims Processing Edits page.

For questions about this policy or to provide more information about a claim, health care providers can contact the Humana Provider Payment Integrity (PPI) Customer Service Department at 1-800-438-7885, 24 hours a day, seven days a week.