The Illinois Department may audit hospital claims for payment for emergency services provided to a recipient who does not require admission as an inpatient. The Illinois Department shall adopt rules that describe how the emergency services audit process will be conducted. These rules shall include, but need not be limited to, the following provisions:
(1)The determination that an emergency medical condition exists shall be based upon the symptoms and condition of the recipient at the time the recipient is initially examined by the hospital emergency department and not upon the final determination of the recipient's actual medical condition.
(2)The Illinois Department or its authorized representative shall meet with the chief executive officer of the hospital, or a person designated by th
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The Illinois Department may audit hospital claims for payment for emergency services provided to a recipient who does not require admission as an inpatient. The Illinois Department shall adopt rules that describe how the emergency services audit process will be conducted. These rules shall include, but need not be limited to, the following provisions: (1) The determination that an emergency medical condition exists shall be based upon the symptoms and condition of the recipient at the time the recipient is initially examined by the hospital emergency department and not upon the final determination of the recipient's actual medical condition. (2) The Illinois Department or its authorized representative shall meet with the chief executive officer of the hospital, or a person designated by the chief executive officer, upon arrival at the hospital to conduct the audit and before leaving the hospital at the conclusion of the audit. The purpose of the pre-audit meeting shall be to inform the hospital concerning the scope of the audit. The purpose of the post-audit meeting shall be to provide the hospital with the preliminary findings of the audit. (3) An emergency services audit shall be limited to a review of records related to services rendered within 6 years of the date of the audit. The hospital's business and professional records for at least 12 previous calendar months shall be maintained and available for inspection by authorized Illinois Department personnel on the premises of the hospital. Illinois Department personnel shall make requests in writing to inspect records more than 12 months old at least 2 business days in advance of the date they must be produced. (4) Where the purpose of the audit is to determine the appropriateness of the emergency services provided, any final determination that would result in a denial of or reduction in payment to the hospital shall be made by a physician licensed to practice medicine in all of its branches who is board certified in emergency medicine or by the appropriate health care professionals under the supervision of the physician. (5) The preliminary audit findings shall be provided to the hospital within 120 days of the date on which the audit conducted on the hospital premises was completed. (6) The Illinois Department or its designated review agent shall use statistically valid sampling techniques when conducting audits.