Independence Blue Cross (IBX) is rolling out a severity-based payment approach for emergency inpatient admissions under Medicare Advantage, following a similar policy from Aetna that took effect earlier this year.
Under the new policy, effective March 5, IBX will use InterQual clinical criteria to determine the payment level for emergent inpatient admissions of five days or fewer. Admissions that meet InterQual acute inpatient criteria will be reimbursed at the hospital’s contracted DRG rate. Those that do not will be paid at the observation rate.
The policy applies to hospitals reimbursed under DRG or case rate methodologies and does not apply to facilities on per diem contracts.
IBX said that the InterQual review is a payment-level determination, not a medical necessity review, and does not affect coverage decisions. Providers can request a review of the payment determination, including a discussion with a medical director.
The policy carves out exceptions for cases involving unexpected death, CMS inpatient-only procedures, newly initiated mechanical ventilations, behavioral health admissions, long-term acute care stays and acute rehabilitation confinements.
Aetna introduced a similar “level of severity inpatient payment” policy for its MA plans in 2026 after delaying its original start date last year following pushback from the American Hospital Association.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.
