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.