FROM: Theodore O. Will, Chief Executive Officer
DATE: Jan 06, 2004
SUBJECT: Implementation of Medicare Long-Term Care Hospital Review Activities
IPRO CONTACTS:
Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, extension 364 or Alice Vallar, Senior Director, Medicare/Federal Health Care Assessment, extension 423
The purpose of this memorandum is to make you aware of long-term care hospital (LTCH) Medicare review activities that will be implemented by IPRO, the Quality Improvement Organization (QIO) for New York.
On August 30, 2002, the Centers for Medicare and Medicaid Services (CMS) published the "Prospective Payment System for Long-Term Care Hospitals (LTCHs): Implementation and Fiscal Year 2003 Rates Final Rule". One of the provisions of this final rule requires QIOs to perform admission and quality reviews in LTCHs.
Regulations found at 42 CFR 412.508 indicate that a LTCH must have an agreement with a QIO to perform reviews on an ongoing basis; to review the medical necessity, reasonableness, and appropriateness of hospital admissions and discharges and of inpatient hospital care for which outlier payments are sought; to review the validity of the hospital's diagnostic and procedural information; to review the completeness, adequacy, and quality of the services furnished in the hospital; and to review other medical or other practices with respect to beneficiaries or billing for services furnished to beneficiaries.
Beginning in February 2004, IPRO will implement case review activities in the following categories, as defined by CMS:
IPRO will review all claims for which the Medicare FI revises the DRG assignment in response to the facility's request to ensure that coded diagnostic and procedural information, as well as the discharge status of the patient, match the information in the patient's medical record.
Hospital Issued Notices of Non-coverage (HINNs) reviews occur to evaluate the hospital's determination that a patient does not require admission, no longer requires medical services, or no longer requires services in a specific setting and is therefore liable for costs incurred following receipt of the notice.
LTCH cases may be referred to an IPRO for review based on a number of reasons. The source of a referral can include:
This review occurs when a beneficiary (or his/her authorized representative) alleges in writing that the quality of services does not meet professionally recognized standards of health care.
Beneficiary complaint reviews may be concurrent (while patient is still in the facility) or retrospective (patient is no longer in the facility).
A cost outlier review occurs when the estimated cost of the case exceeds the high-cost outlier threshold and CMS/FI requests IPRO review.
IPRO will be offering a training session to help LTCH staff understand the Medicare case review process. Download Long-Term Care Hospital Case Review Manual for your review prior to the training session. Additional copies will be available for all attendees the day of the training.
Date/Time: Wednesday. January 21, 2004, 10AM to 1PM
Location: IPRO, Lake Success Corporate Office, Board Room
How many may attend: 5
Who should attend: Utilization Review / Utilization Management personnel, Medical Records personnel, DRG coders
Please complete the registration form and return it by January 14, 2004.
Should you have any questions or require additional information, please feel free to contact Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, extension 364 or Alice Vallar, Senior Director, Medicare/Federal Health Care Assessment, extension 423.