Author: Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI | October 21, 2026
Last week Dr. Mark Spoolstra, the physician advisor at Trinity Health Grand Rapids, sent me a recent bulletin from Blue Cross of Michigan that applies to all of their Medicare Advantage (MA) products in the state.
The memo starts with the usual niceties, explaining the important role in discharge planning when patients are hospitalized, and notes that “discharge planning should begin early in the hospitalization and be reassessed as the patent’s needs change.” That makes sense, and I am sure every hospital strives to start that plan as soon as possible.
But then they go off the rails. Blue Cross states that “providers submitting an authorization request for an acute inpatient medical and surgical admission for a member will be required to include the member’s discharge planning evaluation along with the clinical information required for the request.”
They go on to describe the elements of a discharge planning evaluation, including an anticipated discharge disposition and date, the patient’s clinical needs at discharge, the patient’s functional and social needs, and the availability of post-acute care services for the patient.
This policy makes no sense. Does this payer think that case managers are lined up in the ED waiting for new patients so they can push the medical team aside and start developing a discharge plan before there is even a diagnosis or treatment plan, so they can have it ready to send with the request for approval of inpatient admission? Do they expect the case manager to call the family to talk about discharge plans for their critically ill loved one even before it is known if they will survive their acute illness, so the hospital can notify Blue Cross of the inpatient admission?
Now, I could go into the nuances of this policy and point out that not only is this requirement utterly impossible to meet, but it also has a giant loophole. If you read the policy carefully, it states that it applies to a request for “an acute inpatient medical and surgical admission.” Admissions are either medical or surgical, and not both. So, one could argue that this policy actually applies to absolutely no patient at all. But I suspect the payer will not accept that argument.
This led me to review the payer’s other policies, and there is one indicating that “When an admission occurs through the emergency room, Blue Cross Network asks that the facility contact the primary care provider prior to admission to discuss the member’s medical condition and to coordinate care prior to admitting.” It is not the role of the emergency department physician or staff to do this. Once the patient is hospitalized and stabilized, only then should such coordination begin.
Now, perhaps they are channeling the policy of another payer that expects hospitals to “coordinate the care” by ensuring only in-network providers are used, but that is far from clear from the policy wording.
I can envision a patient presenting to the emergency department with sepsis and metabolic encephalopathy, who receives patient-centered, efficient, evidence-based care, and is transferred to the intensive care unit (ICU). The notification of inpatient admission is sent and inpatient admission approval is denied due to lack of a formal discharge plan.
Two days later, now that the patient’s mental status has cleared, family is available, and they are transferred out of the ICU, a discharge plan is started, but the inpatient admission request will be denied “as the patient’s condition no longer warrants inpatient admission.”
Our country’s healthcare payment system is beyond complex, but policies such as this cannot be justified. The medical care of the patient must be prioritized.
Penalizing providers for doing such has no ethical basis and must be fought.
This article was originally published on RACmonitor.
