FROM: Theodore O. Will, Chief Executive Officer
DATE: Oct 07, 1999
SUBJECT: Medicare Review Of Critical Access Hospital (CAH) Acute Care Inpatient Stay
IPRO CONTACTS:
Alice Vallar, Sr. Director, Medicare and Medicaid Review, ext. 539
Background -- Critical Access Hospitals (CAHs) were created under a 1997 federal budget law as a means of assuring inpatient Medicare services in rural areas (section 1820 of the Social Security Act, as amended by section 4201 of the Balanced Budget Act of 1997). Under Medicare's Rural Hospital Flexibility Program, states apply for designation of CAHs. Those institutions that had been recognized as Rural Primary Care Hospitals prior to August 5, 1997 were automatically designated as CAHs.
In order to be recognized as a Medicare CAH, a hospital usually must be located more than 35 miles from another hospital; provide 24 hour emergency care services; have no more than 15 acute care beds; and limit stays to no more than 96 hours. Peer Review Organizations like IPRO are permitted to waive the 96-hour stay limit on a case-by-case basis.
IPRO's Review Process -- CAHs may request waivers of 96-hour stay limits, by telephone, no less than five (5) hours prior to the expiration of the 96-hour stay. Simultaneously, CAHs must send complete medical records to IPRO. Upon receipt of records, IPRO will determine:
IPRO will complete the review and provide notification of the final determination to the CAH within one (1) working day after receipt of the medical records.
If the waiver is approved, IPRO will notify the CAH of the approval determination (including the number of days approved) and the prior authorization code assigned to the case.
If IPRO denies the waiver request or the entire inpatient stay, the CAH will be notified and a written denial notice will be issued. The notice will be sent to the CAH, attending physician, and the beneficiary. A beneficiary, physician or CAH who is dissatisfied with the initial denial determination may request an expedited reconsideration in writing or by telephoning IPRO at 1-800-446-2447. Written requests should be faxed to (516) 326-6143. If an expedited reconsideration is not filed timely, a nonexpedited reconsideration may still be requested.
Please be aware that IPRO's waiver approval does not relieve the CAH or the attending physician of the responsibility for monitoring the beneficiary's condition/level of care changes, or for making appropriate discharge planning. If after the waiver is granted, the beneficiary's condition/level of care changes and acute care is no longer needed, then the CAH must discharge (from an acute level of care) the beneficiary. Additionally, upon receiving a waiver approval, if the CAH finds that the beneficiary's medical condition requires care beyond the initial days approved, another request for waiver extension must be submitted.
Validation Review-- IPRO will select and retrospectively review a post payment sample of medical records to ensure that the CAH is taking appropriate action when the patient's condition no longer needs acute care.
Should you have any questions or require clarification in regard to this memorandum, please call Alice Vallar, Sr. Director, Medicare/Medicaid Review.