Current through Register Vol. 50, No. 9, September 20, 2024
A. In those instances when an emergency
hospital admission is involved, an admission review is conducted. Admission
review determines the medical appropriateness of the admission and utilizes the
same techniques employed in pre-admission certification review such as
reviewing all pertinent medical information against a set of accepted medical
criteria to evaluate the need for hospital level of care. Non-emergency
admissions that have not been pre-certified by pre-admission certification
review are also monitored through admission review. If the admission is
considered appropriate, a reasonable length of stay is assigned using a set of
standard criteria. The admission review and continued stay review follow the
sequence below.
B. Continued stay
review is the review of the appropriateness and necessity of continued
hospitalization while the patient is still in the hospital. The review is
conducted using acceptable medical criteria to evaluate the appropriateness of
continued hospital level of care. The same criteria used in pre-admission
certification review are used during continued stay review. The day before the
expected discharge date, the case is reviewed to determine if hospital level of
care is still needed. If additional inpatient care is necessary, review
personnel will authorize an extension of the length of stay.
C. Continued stay review is an integral part
of managed care. During continued stay review, review personnel can identify
cases that will benefit from individual case management. Continued stay review
permits the review personnel to become aware of changes in a patient's
condition or slow recovery which may necessitate a longer hospital
stay.
D. Admission and Continued
Stay Review Procedures
1. The
carrier/self-insured employer will automatically review the necessity for
continued hospitalization the day before the initial length of stay assigned
expires without claimant initiation responsibility. The responsibility to
request an extension may be delegated to the hospital if requested by the
hospital and agreed to in writing by the carrier/self-insured employer. If the
party who has the responsibility for initiating the continued stay review fails
to do so, they will be responsible for the cost of any subsequent care
provided.
2. Continued stay review
will include telephone discussions with the hospital or physician if the
information required is not available from the hospital. All pertinent
information necessary to determine if continued hospitalization is medically
necessary and appropriate will be gathered (i.e., current medications and
methods of administration used, frequency, lab values, and results of
diagnostic tests). If re-certification is appropriate, additional days are
assigned based upon statistical norms indicated in the PAS manual using the
next higher percentile adjusted by the medical judgement of the reviewer, if
applicable. This process will continue until the patient is discharged or until
documentation no longer supports the medical necessity for inpatient services.
If re-certification is not medically necessary or appropriate based upon
documentation reviewed, the medical director will issue a denial to the
physician, claimant, and hospital by the close of business (4:30 p.m. Central
Time) on the day of the review.
3.
All nonelective acute care hospital admissions including emergencies,
psychiatric admissions, and all extended hospitalizations are reviewed using
nationally accepted criteria designed to assess the need for hospital level of
care. The Appropriateness Evaluation Protocol (AEP) and the
Intensity/Severity/Discharge (ISD) criteria are the two most prominent
nationally accepted criteria for admissions.
4. Automated software support for the review
process is recommended in order to assure timely responses, uniform
administration and complete data gathering. Computer prompts may be especially
important in following up on length of stay assignments and assuring timely
continued stay review.
5.
Registered nurses use written criteria to assess the need for continued stays
in the hospital. Physicians review all questionable cases and will make the
final carrier/self-insured employer decisions on all denials of
certification.
6.
a. An appeals process must be available for
reconsideration of any denial decisions. If the admitting/treating physician,
hospital, or claimant desires to appeal a denial of an admission or continued
stay request, the appeals process is initiated by contacting the
carrier/self-insured employer by telephone or other immediate means following
receipt of the denial. After the appeal request is received, it will be
referred to the carrier/self-insured employer medical director or physician
consultant. The carrier/self-insured employer medical director or physician
consultant will review the available information regarding the request and make
a decision concerning the appeal within 48 hours of receipt/communication of
the appeal.
b. If the
carrier/self-insured employer medical director's decision is an approval of the
appeal the admitting/treating physician and hospital will be immediately
notified via telephone and follow up by letter will be sent to the physician,
claimant, and hospital.
c. If the
carrier/self-insured employer medical director's decision is a denial the
carrier/self-insured employer will notify the admitting/treating physician and
hospital and will immediately submit in writing the denial and case
documentation by fax to the director of the Office of Workers' Compensation for
review at (225) 342-6556.** The material should be clearly identified as a
denial of an admission or continued hospital stay request and should be
addressed "Attention: Medical Manager, Office of Workers' Compensation." The
director will immediately review the case and will notify the
carrier/self-insured employer, the admitting/treating physician, and hospital
by telephone of his agreement or disagreement with the denial decision.
Follow-up notification will be sent to the claimant, carrier/self-insured
employer, hospital, and admitting/treating physician by certified mail return
receipt requested. Any party who disagrees with the director's resolution may
file a Disputed Claim for Compensation Form (LDOL-WC-1008), available from the
Office of Workers' Compensation Administration as otherwise provided by
law.
7. The review
process is also used to identify and refer cases for discharge
planning.
8. The program includes
written notification of the continued stay review decision to the claimant,
physician and the hospital.
9. The
carrier/self-insured employer maintains appropriate internal documentation of
each request for continued stay review to verify the process and the decision
for claims processing and reporting purposes.
E. Admission And Continued Stay Review
Preparation
1. Preparation
a. Educational Program for Providers. The
carrier/self-insured employer will maintain and make available to the provider
information regarding the admission and continued stay review certification
program, describing the reasons for implementation and operation, including an
explanation of the appeals process. This notice of the admission and continued
stay review program may be included in local carrier/self-insured employer
provider newsletters.
b. Admission
and Continued Stay Review Forms. The carrier/self-insured employer may use
samples (Exhibit 1 and 2, Clauses E.1.d.i and ii) or develop forms to capture
pertinent patient and provider information during the admission and continued
stay review activity. These forms may be identical to those used by the
carrier/self-insured employer for their other business, however, they should
capture the statistical data elements required by the Office of Workers'
Compensation Administration.
c.
Standardized Form Letters. The carrier/self-insured employer will develop
letters announcing the results of the admission and continued stay review
process to:
i. claimant;
ii. the admitting/treating physician;
and
iii. the hospital, with appeals
process information where necessary.
d. Exhibits of Form Letters
i. Exhibit 3-A-Continued Stay Approval Letter
|
Re: Patient:
Pre-Admission Certification No.:
Claimant No.:
Date of Service:
Hospital:
Additional days to the hospital referenced above
have been approved based upon a determination of medical necessity for
continued inpatient care. A total of (indicate number of days) days is
available for this hospital stay.
it is important for you to know that ...
This approval of the inpatient hospital setting is
based on information provided by the above listed hospital and/or physician.
the determination of actual benefits ...
Can only be made upon receipt of completed claim.
Payment for the services received is subject to statutory limitations.
Eligibility is dependent upon:
1. the medical necessity for the services
provided; and
2. the work-relatedness of the illness or injury.
if the claimant requires continued hospitalization
beyond the number of days approved ...
The admitting physician or authorized hospital
representative should contact the carrier/self-insured employer at (phone
number) on or before the above days expire.
benefits for services rendered during additional
hospital days not certified may be denied.
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ii. Exhibit 3-C-Continued Stay Denial Letter
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Re: Patient:
Pre-Certification No.:
Contract No.:
Date of Service:
Hospital:
Dear (claimant/physician/provider)
The medical director has reviewed carefully your
current medical status and, based upon the information obtained, has determined
that the medical necessity of further hospitalization has not been documented.
Charges for inpatient services after (date), at
the hospital referenced above will not be considered for payment.
If you disagree with this decision, you may appeal
in accordance with the guidelines attached.
Sincerely,
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2. Implementation
a. Telephone Inquiry Service. Telephone
numbers should be published in educational materials and standardized form
letters to the physicians, hospitals, and claimants. This telephone service
allows for prompt response to requests for review and to general inquires about
the review process.
b. Appropriate
Staff and Documentation for Program Management of Certified, Denied, and
Appealed Admissions. Registered nurses and physicians are the recommended staff
for processing of admission and continued stay review requests and inquires.
Procedures must be available for timely review of appealed or denied admissions
by a physician (a psychiatrist for mental illness or substance abuse
admissions). Program procedures should be routine and documented.
3. Evaluation
a. Data Collection. Admission and continued
stay review documentation should be linked to the claims system to properly
process inpatient claims. The admission and continued stay review documentation
should be retrievable on a claim-by-claim basis for compilation and
classification of activity performance.
b. Carrier/Self-Insured Employer Data
Reporting. Carrier/self-insured employer will be required to collect data
according to the Office of Workers' Compensation Administration requirements:
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Information
|
Positions
|
Type
|
|
ICD-10-CM
|
5/7
|
Numeric
|
|
Provider Name
|
30
|
Alpha
|
|
Provider Street Address
|
30
|
Alpha Numeric
|
|
Parish Code for Provider of Service
(Use Standard FIPS code, see Exhibit 5)
|
3
|
Numeric
|
|
Place of Treatment
|
1
|
Alpha Numeric
|
|
Type of Facility*
|
6
|
Numeric
|
|
Type of Service:
Medical vs. Surgical
|
1
|
Alpha Numeric
|
|
Claimant Name
|
30
|
Alpha
|
|
Claimant Social Security Number
|
9
|
Numeric
|
|
Length of Stay
|
4
|
Numeric
|
|
* See "Type Facility Codes" in Exhibit 6.
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The telephone
number for the Office of Workers' Compensation has been changed to (225)
342-7555.**
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
23:1291.
