§ 2803-I — General hospital inpatient discharge review program

§ 2803-i. General hospital inpatient discharge review program. 1. A\ngeneral hospital inpatient discharge review program applicable to all\npatients other than beneficiaries of title XVIII of the federal social\nsecurity act (medicare) shall be established in accordance with this\nsection. No general hospital inpatient subject to the provisions of this\nsection may be discharged on the basis that inpatient hospital service\nin a general hospital is no longer medically necessary and that an\nappropriate discharge plan has been established unless a written notice\nof such determinations and a copy of the discharge plan have been\nprovided to the patient or the appointed personal representative of the\npatient. The patient or the appointed personal representative of the\npatient shall have the opportunity to sign the notice and a copy of the\ndischarge plan and receive a copy of both signed documents. Every\ngeneral hospital shall use a common notice developed and disseminated in\naccordance with rules and regulations adopted by the council and\napproved by the commissioner which shall indicate that the patient is to\nbe discharged, shall state the reasons therefor and shall state that the\npatient may request a review of such determinations. The patient, or the\nappointed personal representative of the patient may request a review of\nsuch determinations by the appropriate independent professional review\nagent (or "review agent") in accordance with subdivision four of this\nsection. Notwithstanding that the patient discharge review process\nprovided in accordance with federal law and regulation shall apply to\nbeneficiaries of title XVIII of the federal social security act\n(medicare), a written copy of the discharge plan, and discharge notice\nshall be provided to the beneficiary or the appointed personal\nrepresentative of the beneficiary. The beneficiary or the appointed\npersonal representative of the beneficiary shall have the opportunity to\nsign the documents and receive a copy of the signed documents.\n 2. (a) For patients eligible for payments by state governmental\nagencies for general hospital inpatient services as the patient's\nprimary payor, an independent professional review agent shall mean the\ncommissioner or his designee. In conducting general hospital inpatient\ndischarge reviews in accordance with this section, the commissioner may\nutilize the services of department personnel or other authorized\nrepresentatives, including a review agent approved in accordance with\nparagraph (b) of this subdivision.\n (b) For patients who are not beneficiaries of title XVIII of the\nfederal social security act (medicare) nor eligible for payments by\nstate governmental agencies as the patient's primary payor, an\nindependent professional review agent shall mean a third party payor of\nhospital services or other corporation approved by the commissioner in\nwriting for purposes of conducting general hospital inpatient discharge\nreviews in accordance with this section. For a third party payor of\nhospital services or other corporation to be approved as an independent\nprofessional review agent in accordance with this paragraph, such third\nparty payor or other corporation must meet the following criteria: (i)\nthe review agent shall employ or otherwise secure the services of\nadequate medical personnel qualified to determine the necessity of\ncontinued inpatient hospital services and the appropriateness of\nhospital discharge plans; (ii) the review agent shall demonstrate the\nability to render review decisions in a timely manner as provided in\nthis section; (iii) the review agent shall agree to provide ready access\nby the commissioner to all data, records and information it collects and\nmaintains concerning its review activities under this section; (iv) the\nreview agent shall agree to provide to the commissioner such data,\ninformation and reports as the commissioner determines necessary to\nevaluate the review process provided pursuant to this section; (v) the\nreview agent shall provide assurances that review personnel shall not\nhave a conflict of interest in conducting a discharge review for a\npatient based on hospital or professional affiliation; and (vi) the\nreview agent meets such other performance and efficiency criteria\nregarding the conduct of reviews pursuant to this section established by\nthe commissioner. The commissioner may withdraw approval of an\nindependent professional review agent where such review agent fails to\ncontinue to meet approval criteria established pursuant to this\nparagraph.\n (c) (i) Each general hospital shall enter into contracts with one or\nmore independent professional review agents approved by the commissioner\nin accordance with paragraph (b) of this subdivision for purposes of\nconducting general hospital inpatient discharge reviews in accordance\nwith this section for patients, including uncompensated care patients,\nwho are not beneficiaries of title XVIII of the federal social security\nact (medicare) nor eligible for payments by state governmental agencies\nas the patients' primary payor; provided, however, a payor of hospital\nservice included in the payor categories specified in paragraph (a) of\nsubdivision one of section twenty-eight hundred seven-c of this article,\nother than state governmental agencies, may designate the review agent\nfor their subscribers or beneficiaries or enrolled members and shall\nreimburse such designated review agent for costs of the discharge review\nprogram.\n (ii) Notwithstanding any inconsistent provision of law, general\nhospital contract costs incurred in accordance with subparagraph (i) of\nthis paragraph may be included as an additional charge for general\nhospital inpatient services in determining patient charges for payors\nincluded in the payor categories specified in paragraph (c) of\nsubdivision one of section twenty-eight hundred seven-c of this article,\nor as a charge in addition to rates of payment for general hospital\ninpatient services in determining payment due for payors included in the\npayor categories specified in paragraph (b) of subdivision one of\nsection twenty-eight hundred seven-c of this article, or paragraph (a)\nof such subdivision one if a payor has not designated a review agent for\nsuch payor's subscribers or beneficiaries or enrolled members, or\nparagraph (a) or (b) of subdivision two of section twenty-eight hundred\nseven-c of this article. Such additional charges shall not be subject to\nmaximum charge or rate of payment ceilings determined in accordance with\nsection twenty-eight hundred seven-c of this article for such payors.\n 3. (a) If a general hospital and the attending physician agree that\ninpatient hospital service in a general hospital is no longer medically\nnecessary for a patient, other than a beneficiary of title XVIII of the\nfederal social security act (medicare), and an appropriate discharge\nplan has been established for such patient, at that time the hospital\nshall provide the patient or the appointed personal representative of\nthe patient with a written discharge notice and a copy of the discharge\nplan, meeting the requirements of subdivision one of this section.\n (b) If a general hospital has determined that inpatient hospital\nservice in a general hospital is no longer medically necessary for a\npatient, other than a beneficiary of title XVIII of the federal social\nsecurity act (medicare), and an appropriate discharge plan has been\nestablished for such patient but the attending physician has not agreed\nwith the hospital's determinations, the hospital may request by\ntelephone a review of the validity of the hospital's determinations by\nthe appropriate independent professional review agent. Such review agent\nshall conduct a review of the hospital's determinations and prior to the\nconclusion of the review shall provide an opportunity to the treating\nphysician and an appropriate representative of the hospital to confer\nand provide information which may include the patient's clinical records\nif requested by the review agent. Such review agent shall notify the\nhospital of the results of its review not later than one working day\nafter the date the review agent has received the request, the records\nrequired to conduct such review, and the date of such conferring and\nreceipt of any additional information requested. The hospital shall\nprovide notice to the attending physician of the results of the review.\nIf the review agent concurs with the hospital's determinations, the\nhospital shall provide the patient or his appointed personal\nrepresentative with a written notice of such determinations and notice\nthat the patient shall be financially responsible for continued stay,\nand with a copy of the proposed discharge plan. The patient or the\nappointed personal representative of the patient shall have the\nopportunity to sign the notice and a copy of the proposed discharge plan\nand receive a copy of both signed documents. Every general hospital\nshall use a common notice developed and disseminated in accordance with\nrules and regulations adopted by the council and approved by the\ncommissioner which shall indicate the determinations made, shall state\nthe reasons therefor and that the patient's attending physician has\ndisagreed and shall state that the patient or the appointed personal\nrepresentative of the patient may request a review of such\ndeterminations by the appropriate review agent.\n 4. A patient in a general hospital, or the appointed personal\nrepresentative of the patient, who receives a written notice in\naccordance with paragraph (a) or (b) of subdivision three of this\nsection, may request a review by the appropriate review agent of the\ndeterminations set forth in such notice related to medical necessity of\ncontinued inpatient hospital service, the appropriateness of the\ndischarge plan and the availability of required continuing health care\nservices.\n (a) If a patient while still hospitalized or while no longer an\ninpatient, or the appointed personal representative of such patient,\nrequests a review by the appropriate review agent, the hospital shall\npromptly provide to the review agent the records required to review the\ndeterminations. Such request for a patient no longer an inpatient shall\ntake place no later than thirty days after receipt of a notice provided\nin accordance with subdivision three of this section or seven days after\nreceipt of a complete bill for all inpatient services rendered,\nwhichever is later. The review agent shall conduct a review of such\ndeterminations and shall provide the treating physician and an\nappropriate representative of the hospital with an opportunity to confer\nand provide information prior to the conclusion of the review. The\nreview agent shall provide written notice to the patient, or the\nappointed personal representative of the patient, and the hospital of\nthe results of the review within three working days of receipt of the\nrequests for review and the records required to review the\ndeterminations. The hospital shall provide notice to the attending\nphysician of the results of the review.\n (b) Notwithstanding the provisions of paragraph (a) of this\nsubdivision, if a patient while still an inpatient in the general\nhospital, or the appointed personal representative of the patient,\nrequests a review by the appropriate review agent not later than noon of\nthe first working day after the date the patient, or the appointed\npersonal representative of the patient, receives the written notice, the\nhospital shall provide to the appropriate review agent the records\nrequired to review the determinations by the close of business of such\nworking day. The appropriate review agent shall conduct a review of such\ndeterminations and provide written notice to the patient, or the\nappointed personal representative of the patient, and the hospital of\nthe results of the review not later than one full working day after the\ndate the review agent has received the request for review and such\nrecords. The hospital shall provide notice to the attending physician of\nthe results of the review.\n 5. Notwithstanding any inconsistent provision of law, if the\nappropriate review agent, upon any review conducted pursuant to\nparagraph (b) of subdivision three or pursuant to subdivision four of\nthis section does not concur in the determinations, continued stay in a\ngeneral hospital shall be deemed necessary and appropriate for the\npatient for purposes of payment for such continued stay in accordance\nwith section twenty-eight hundred seven-c of this article.\n 6. If a patient eligible for payment for inpatient hospital services\nunder a case based payment per discharge determined in accordance with\nsection twenty-eight hundred seven-c of this article, or the appointed\npersonal representative of the patient, requests a review by the\nappropriate review agent in accordance with paragraph (b) of subdivision\nfour of this section, the hospital may not demand or request any payment\nfor additional inpatient hospital services provided to such patient\nsubsequent to the proposed time of discharge and prior to noon of the\nday after the date the patient or the appointed personal representative\nof the patient receives notice of the results of the review by the\nreview agent other than payment determined in accordance with section\ntwenty-eight hundred seven-c of this article and deductibles,\ncopayments, or other charges that would be authorized for a patient for\nwhom inpatient hospital services in a general hospital continue to be\nnecessary and appropriate.\n 7. In any review conducted pursuant to paragraph (b) of subdivision\nthree or pursuant to subdivision four of this section, the review agent\nshall solicit the views of the patient involved, or the appointed\npersonal representative of the patient, and the attending physician.\n 8. Each patient, or the appointed personal representative of the\npatient, provided a notice by a general hospital in accordance with\nsubdivision three of this section shall be provided at such time by the\nhospital with a notice, in a form developed in accordance with rules and\nregulations adopted by the council and approved by the commissioner, of\nsuch patient's right to request a discharge review in accordance with\nthis section. The patient or the appointed personal representative of\nthe patient shall have the opportunity to sign this form and receive a\ncopy of the signed form.\n 9. Upon discharge of a blind or visually impaired patient, a hospital\nshall offer to provide the patient's discharge plan in a large print\nversion or, at the patient's or patient's representative's request, as\nan audio recording, to be made available to such patient or such\npatient's representative on compact disc or other medium as the hospital\nmay offer, or as an electronically transmitted digital file, in addition\nto a written copy of the discharge plan.\n 10. The council shall adopt rules and regulations, subject to the\napproval of the commissioner, necessary to implement this section.\n