N.Y. Public Health Law § 2803-i: General hospital inpatient discharge review program

§ 2803-i. General hospital inpatient discharge review program. 1. A

general hospital inpatient discharge review program applicable to all

patients other than beneficiaries of title XVIII of the federal social

security act (medicare) shall be established in accordance with this

section. No general hospital inpatient subject to the provisions of this

section may be discharged on the basis that inpatient hospital service

in a general hospital is no longer medically necessary and that an

appropriate discharge plan has been established unless a written notice

of such determinations and a copy of the discharge plan have been

provided to the patient or the appointed personal representative of the

patient. The patient or the appointed personal representative of the

patient shall have the opportunity to sign the notice and a copy of the

discharge plan and receive a copy of both signed documents. Every

general hospital shall use a common notice developed and disseminated in

accordance with rules and regulations adopted by the council and

approved by the commissioner which shall indicate that the patient is to

be discharged, shall state the reasons therefor and shall state that the

patient may request a review of such determinations. The patient, or the

appointed personal representative of the patient may request a review of

such determinations by the appropriate independent professional review

agent (or "review agent") in accordance with subdivision four of this

section. Notwithstanding that the patient discharge review process

provided in accordance with federal law and regulation shall apply to

beneficiaries of title XVIII of the federal social security act

(medicare), a written copy of the discharge plan, and discharge notice

shall be provided to the beneficiary or the appointed personal

representative of the beneficiary. The beneficiary or the appointed

personal representative of the beneficiary shall have the opportunity to

sign the documents and receive a copy of the signed documents.

2. (a) For patients eligible for payments by state governmental

agencies for general hospital inpatient services as the patient's

primary payor, an independent professional review agent shall mean the

commissioner or his designee. In conducting general hospital inpatient

discharge reviews in accordance with this section, the commissioner may

utilize the services of department personnel or other authorized

representatives, including a review agent approved in accordance with

paragraph (b) of this subdivision.

(b) For patients who are not beneficiaries of title XVIII of the

federal social security act (medicare) nor eligible for payments by

state governmental agencies as the patient's primary payor, an

independent professional review agent shall mean a third party payor of

hospital services or other corporation approved by the commissioner in

writing for purposes of conducting general hospital inpatient discharge

reviews in accordance with this section. For a third party payor of

hospital services or other corporation to be approved as an independent

professional review agent in accordance with this paragraph, such third

party payor or other corporation must meet the following criteria: (i)

the review agent shall employ or otherwise secure the services of

adequate medical personnel qualified to determine the necessity of

continued inpatient hospital services and the appropriateness of

hospital discharge plans; (ii) the review agent shall demonstrate the

ability to render review decisions in a timely manner as provided in

this section; (iii) the review agent shall agree to provide ready access

by the commissioner to all data, records and information it collects and

maintains concerning its review activities under this section; (iv) the

review agent shall agree to provide to the commissioner such data,

information and reports as the commissioner determines necessary to

evaluate the review process provided pursuant to this section; (v) the

review agent shall provide assurances that review personnel shall not

have a conflict of interest in conducting a discharge review for a

patient based on hospital or professional affiliation; and (vi) the

review agent meets such other performance and efficiency criteria

regarding the conduct of reviews pursuant to this section established by

the commissioner. The commissioner may withdraw approval of an

independent professional review agent where such review agent fails to

continue to meet approval criteria established pursuant to this

paragraph.

(c) (i) Each general hospital shall enter into contracts with one or

more independent professional review agents approved by the commissioner

in accordance with paragraph (b) of this subdivision for purposes of

conducting general hospital inpatient discharge reviews in accordance

with this section for patients, including uncompensated care patients,

who are not beneficiaries of title XVIII of the federal social security

act (medicare) nor eligible for payments by state governmental agencies

as the patients' primary payor; provided, however, a payor of hospital

service included in the payor categories specified in paragraph (a) of

subdivision one of section twenty-eight hundred seven-c of this article,

other than state governmental agencies, may designate the review agent

for their subscribers or beneficiaries or enrolled members and shall

reimburse such designated review agent for costs of the discharge review

program.

(ii) Notwithstanding any inconsistent provision of law, general

hospital contract costs incurred in accordance with subparagraph (i) of

this paragraph may be included as an additional charge for general

hospital inpatient services in determining patient charges for payors

included in the payor categories specified in paragraph (c) of

subdivision one of section twenty-eight hundred seven-c of this article,

or as a charge in addition to rates of payment for general hospital

inpatient services in determining payment due for payors included in the

payor categories specified in paragraph (b) of subdivision one of

section twenty-eight hundred seven-c of this article, or paragraph (a)

of such subdivision one if a payor has not designated a review agent for

such payor's subscribers or beneficiaries or enrolled members, or

paragraph (a) or (b) of subdivision two of section twenty-eight hundred

seven-c of this article. Such additional charges shall not be subject to

maximum charge or rate of payment ceilings determined in accordance with

section twenty-eight hundred seven-c of this article for such payors.

3. (a) If a general hospital and the attending physician agree that

inpatient hospital service in a general hospital is no longer medically

necessary for a patient, other than a beneficiary of title XVIII of the

federal social security act (medicare), and an appropriate discharge

plan has been established for such patient, at that time the hospital

shall provide the patient or the appointed personal representative of

the patient with a written discharge notice and a copy of the discharge

plan, meeting the requirements of subdivision one of this section.

(b) If a general hospital has determined that inpatient hospital

service in a general hospital is no longer medically necessary for a

patient, other than a beneficiary of title XVIII of the federal social

security act (medicare), and an appropriate discharge plan has been

established for such patient but the attending physician has not agreed

with the hospital's determinations, the hospital may request by

telephone a review of the validity of the hospital's determinations by

the appropriate independent professional review agent. Such review agent

shall conduct a review of the hospital's determinations and prior to the

conclusion of the review shall provide an opportunity to the treating

physician and an appropriate representative of the hospital to confer

and provide information which may include the patient's clinical records

if requested by the review agent. Such review agent shall notify the

hospital of the results of its review not later than one working day

after the date the review agent has received the request, the records

required to conduct such review, and the date of such conferring and

receipt of any additional information requested. The hospital shall

provide notice to the attending physician of the results of the review.

If the review agent concurs with the hospital's determinations, the

hospital shall provide the patient or his appointed personal

representative with a written notice of such determinations and notice

that the patient shall be financially responsible for continued stay,

and with a copy of the proposed discharge plan. The patient or the

appointed personal representative of the patient shall have the

opportunity to sign the notice and a copy of the proposed discharge plan

and receive a copy of both signed documents. Every general hospital

shall use a common notice developed and disseminated in accordance with

rules and regulations adopted by the council and approved by the

commissioner which shall indicate the determinations made, shall state

the reasons therefor and that the patient's attending physician has

disagreed and shall state that the patient or the appointed personal

representative of the patient may request a review of such

determinations by the appropriate review agent.

4. A patient in a general hospital, or the appointed personal

representative of the patient, who receives a written notice in

accordance with paragraph (a) or (b) of subdivision three of this

section, may request a review by the appropriate review agent of the

determinations set forth in such notice related to medical necessity of

continued inpatient hospital service, the appropriateness of the

discharge plan and the availability of required continuing health care

services.

(a) If a patient while still hospitalized or while no longer an

inpatient, or the appointed personal representative of such patient,

requests a review by the appropriate review agent, the hospital shall

promptly provide to the review agent the records required to review the

determinations. Such request for a patient no longer an inpatient shall

take place no later than thirty days after receipt of a notice provided

in accordance with subdivision three of this section or seven days after

receipt of a complete bill for all inpatient services rendered,

whichever is later. The review agent shall conduct a review of such

determinations and shall provide the treating physician and an

appropriate representative of the hospital with an opportunity to confer

and provide information prior to the conclusion of the review. The

review agent shall provide written notice to the patient, or the

appointed personal representative of the patient, and the hospital of

the results of the review within three working days of receipt of the

requests for review and the records required to review the

determinations. The hospital shall provide notice to the attending

physician of the results of the review.

(b) Notwithstanding the provisions of paragraph (a) of this

subdivision, if a patient while still an inpatient in the general

hospital, or the appointed personal representative of the patient,

requests a review by the appropriate review agent not later than noon of

the first working day after the date the patient, or the appointed

personal representative of the patient, receives the written notice, the

hospital shall provide to the appropriate review agent the records

required to review the determinations by the close of business of such

working day. The appropriate review agent shall conduct a review of such

determinations and provide written notice to the patient, or the

appointed personal representative of the patient, and the hospital of

the results of the review not later than one full working day after the

date the review agent has received the request for review and such

records. The hospital shall provide notice to the attending physician of

the results of the review.

5. Notwithstanding any inconsistent provision of law, if the

appropriate review agent, upon any review conducted pursuant to

paragraph (b) of subdivision three or pursuant to subdivision four of

this section does not concur in the determinations, continued stay in a

general hospital shall be deemed necessary and appropriate for the

patient for purposes of payment for such continued stay in accordance

with section twenty-eight hundred seven-c of this article.

6. If a patient eligible for payment for inpatient hospital services

under a case based payment per discharge determined in accordance with

section twenty-eight hundred seven-c of this article, or the appointed

personal representative of the patient, requests a review by the

appropriate review agent in accordance with paragraph (b) of subdivision

four of this section, the hospital may not demand or request any payment

for additional inpatient hospital services provided to such patient

subsequent to the proposed time of discharge and prior to noon of the

day after the date the patient or the appointed personal representative

of the patient receives notice of the results of the review by the

review agent other than payment determined in accordance with section

twenty-eight hundred seven-c of this article and deductibles,

copayments, or other charges that would be authorized for a patient for

whom inpatient hospital services in a general hospital continue to be

necessary and appropriate.

7. In any review conducted pursuant to paragraph (b) of subdivision

three or pursuant to subdivision four of this section, the review agent

shall solicit the views of the patient involved, or the appointed

personal representative of the patient, and the attending physician.

8. Each patient, or the appointed personal representative of the

patient, provided a notice by a general hospital in accordance with

subdivision three of this section shall be provided at such time by the

hospital with a notice, in a form developed in accordance with rules and

regulations adopted by the council and approved by the commissioner, of

such patient's right to request a discharge review in accordance with

this section. The patient or the appointed personal representative of

the patient shall have the opportunity to sign this form and receive a

copy of the signed form.

9. Upon discharge of a blind or visually impaired patient, a hospital

shall offer to provide the patient's discharge plan in a large print

version or, at the patient's or patient's representative's request, as

an audio recording, to be made available to such patient or such

patient's representative on compact disc or other medium as the hospital

may offer, or as an electronically transmitted digital file, in addition

to a written copy of the discharge plan.

10. The council shall adopt rules and regulations, subject to the

approval of the commissioner, necessary to implement this section.