Current through Register Vol. 48, No. 12, March 22, 2024
Effective for dates of discharge on or after July 1,
2014:
a) General Requirements
1) A hospital must meet the conditions of
this Section to receive payment under the DRG PPS for inpatient hospital
services furnished to persons receiving coverage under the Medicaid
Program.
2) If a hospital fails to
comply fully with these conditions with respect to inpatient hospital services
furnished to one or more Medical Assistance clients, the Department may, as
appropriate:
A) Withhold Medicaid payments
(in full or in part) to the hospital until the hospital provides adequate
assurances of compliance; or
B)
Terminate the hospital's Provider Agreement pursuant to 89 Ill. Adm. Code
140.16.
b) Hospital Utilization
Control: Hospitals and distinct part units that participate in Medicare (Title
XVIII) must use the same utilization review standards and procedures and review
committee for Medical Assistance as they use for Medicare. Hospitals and
distinct part units that do not participate in Medicare (Title XVIII) must meet
the utilization review plan requirements in 42 CFR, Ch. IV, Part 456 (October
1, 2013). Utilization control requirements for inpatient psychiatric hospital
care in a psychiatric hospital, as defined in 89 Ill. Adm. Code
148.25(d)(1),
shall be in accordance with federal regulations.
c) Medical Review Requirements: Admissions
and Quality Review
Hospital utilization review committees, a subgroup of the
utilization review committee, or the hospital's designated professional review
organization (PRO) shall review, on an ongoing basis, the following:
1) The medical necessity, reasonableness and
appropriateness of inpatient hospital admissions and discharges.
2) The medical necessity, reasonableness and
appropriateness of inpatient hospital care for which additional payment is
sought under the outlier provisions of Section
149.105.
3) The validity of the hospital's diagnostic
and procedural information.
4) The
completeness, adequacy and quality of the services furnished in the
hospital.
5) Other medical or other
practice with respect to program participants or billing for services furnished
to program participants.
d) Medical Review Requirements: DRG
Validation. The Department, or its agent, may require and perform pre-
or-post-payment review of diagnosis and procedure codes to verify that the
diagnostic and procedural coding, submitted by the hospital and used by the
Department for DRG assignment, is substantiated by the corresponding medical
records. The review may be undertaken by way of a sample of discharges. The
review may, at the sole discretion of the Department, take place at the
hospital or away from the hospital site.
e) Utilization Review Requirements: The
Department, or its designated peer review organization, as described in 89 Ill.
Adm. Code
148.240(j),
may conduct pre-admission, concurrent, pre-payment, and/or post-payment
reviews, as defined at 89 Ill. Adm. Code 148.240.
f) Furnishing of Inpatient Hospital Services
Directly or Under Other Arrangements
1) The
payments made under the PPS are payment in full for all inpatient hospital
services other than for the services of non hospital-based physicians to
individual program participants and the services of certain hospital-based
physicians as described in subsection (f)(1)(B).
A) Hospital-based physicians who may not bill
separately on a fee-for-service basis are:
i)
A physician whose salary is included in the hospital's cost report for direct
patient care.
ii) A teaching
physician who provides direct patient care, if the salary paid to the teaching
physician by the hospital or other institution includes a component for
treatment services.
B)
Hospital-based physicians who may bill separately on a fee-for-service basis
are:
i) A physician whose salary is not
included in the hospital's cost report for direct patient care.
ii) A teaching physician who provides direct
patient care, if the salary paid to the teaching physician by the hospital or
other institution does not include a component for treatment
services.
iii) A resident, when, by
the terms of his or her contract with the hospital, he or she is permitted to
and does bill private patients and collect and retain the payments received for
those services.
iv) A
hospital-based specialist who is salaried, with the cost of his or her services
included in the hospital reimbursement costs, when, by the terms of his or her
contract with the hospital, he or she may charge for professional services and
does, in fact, bill private patients and collect and retain the payments
received.
v) A physician holding a
nonteaching administrative or staff position in a hospital or medical school,
but only to the extent that he or she maintains a private practice and bills
private patients and collects and retains payments made.
2) Charges are to be submitted on
a fee-for-service basis only when the physician seeking reimbursement has been
personally involved in the services being provided. In the case of surgery, it
means presence in the operating room, performing or supervising the major
phases of the operation, with full and immediate responsibility for all actions
performed as a part of the surgical treatment.