Administrative Memos

200005

FROM: Theodore O. Will, Chief Executive Officer
DATE: Jun 20, 2000
SUBJECT: Medicaid Review Activities
IPRO CONTACTS:

Patti G. Weinberg, Vice President, State/ Medicaid Health Care Evaluation, ext. 617 and Kathleen M. Fox, Director of Reviews, State/ Medicaid Health Care Evaluation, ext.529

As you are aware, IPRO, the State's Medicaid UR agent has been given the responsibility of conducting utilization review activities for the entire state, including the 75 hospitals previously reviewed under the NYSDOH Medicaid UR demonstration project. This administrative memorandum will explain how IPRO will be conducting Medicaid reviews statewide.

IPRO has entered into a subcontract agreement with the Empire State Medical Scientific and Education Foundation (The Foundation) to conduct review activities, predominantly in the upstate, central New York counties. As an independent health care review organization, organized by the Medical Society of The State of New York (MSSNY), The Foundation has been involved in medical review since 1984. All IPRO policies, procedures and criteria will be used by the Foundation staff during the review process. IPRO will perform all sampling activities, as well as appeals, and review of immediate concerns. All fiscal take backs will be processed by IPRO and submitted to MMIS.

Please note that for facilities previously reviewed as part of the demonstration project, IPRO will initially be sampling cases billed on or after March 2000 to avoid duplicate reviews. If you believe that a selected case was previously reviewed, please inform us when you receive the case list.

The Foundation will perform the following review activities:

Retrospective reviews will be performed by Foundation staff for the attached list of upstate hospitals (Exhibit I). These reviews will be conducted both onsite and offsite and will include the following:

Initial Review
Preliminary Denials
Final Determinations
Technical Denial Reopening

For these hospitals, all appeal requests (after receipt of a final determination) and any additional documentation is to be sent to the Foundation for processing. These cases will then be forwarded to IPRO, at our Lake Success office, to be reviewed and completed.

Cost Outlier reviews will be performed both by IPRO as well as the Foundation staff from acute care facilities across the state. The request letters will indicate which site the chart should be sent to. In these cases, the Foundation will perform all levels of review.

As stated in previous administrative memoranda, all other reviews will continue to be onducted by IPRO at our Lake Success offices. These include preprocedure/pre-certification reviews, and IPRA /discharge notice reviews.

For the acute care facilities previously reviewed under the demonstration project and who have cases, which were partially reviewed and/or under appeal, including cost outliers, IPRO is awaiting direction from the NYSDOH on how to proceed. Instructions on how these cases will be handled will be sent in a future memorandum.

Should you have any questions or require additional information, please feel free to call either Patti G. Weinberg, Vice President, State/ Medicaid Health Care Evaluation, Ext. 617 or Kathleen M. Fox, Director of Reviews, State/ Medicaid Health Care Evaluation, Ext. 529.