Beginning in 2022, Blue Cross Blue Shield of Michigan will not approve inpatient admissions for 22 specified diagnoses until a minimum of 48 hours of observation has occurred, except for when the patient is currently being cared for in an intensive care unit (ICU). While this mandate seems logical for certain minor diagnoses, it does not seem so for some of the 22 more serious diagnoses such as heart failure and pneumonia. Also new is that InterQual criteria will not be able to be used until after the required 48 hours of observation has passed.
As a result, to provide more timely medical care, more admissions to ICUs may occur versus general inpatient admissions. This would create financial issues that your facility may not be prepared to handle as well as unanswered questions such as:
- How will your facility be paid?
- Is this policy the same for all Blue Cross Blue Shield and Medicaid products?
- How is inpatient defined in each plan, or is it not defined?
- Does this definition of inpatient meet federal and/or state regulations?
- What are the financial and legal consequences to the facility if it doesn’t meet regulations?
BKD’s Health Care Performance Advisory Services is available to assist you in interpreting payor mandates as well as recommending practices to address compliance concerns. For more information on how we can help, reach out to a BKD Trusted Advisor™ or submit the Contact Us form below.