Administrative Memos

199907

FROM: Theodore O. Will, Chief Executive Officer
DATE: Nov 05, 1999
SUBJECT: Acute Care Facility - Memorandum of Agreement
IPRO CONTACTS:

Enclosed for your review and signature please find two copies of the Memorandum of Agreement (MOA) for Medicare Sixth Scope of Work (6th SOW) review activities between IPRO, as the Federally designated Peer Review Organization for New York State, and your Acute Care Facility. This agreement replaces the MOA currently in effect. It should be noted that your hospital, as a Medicare provider, is required to have a signed MOA with the PRO.

Please have the appropriate representative of your facility sign and return both copies of the MOA by December 3, 1999. A fully executed original will be returned for your files.

Please note that the MOAs for the hospitals affiliated with the Health and Hospitals Corporation, Rehabilitation Centers and Ambulatory Surgery Centers are being mailed for signature under separate cover.

IPRO appreciates the assistance in preparing this MOA received from the members of the Provider Relations Committee, including representatives from the Healthcare Association of New York State (HANYS), Greater New York Hospital Association, Iroquois Healthcare Alliance, Nassau-Suffolk Hospital Council, New York City Health & Hospitals Corporation, Northern Metropolitan Hospital Association, and the Rochester Regional Hospital Association.

Should you or your staff have any questions with regard to this matter, please feel free to contact me or Harry M. Feder, Senior Vice President.

MEMORANDUM OF AGREEMENT

Between and ACUTE CARE FACILITY

This Memorandum of Agreement (MOA) is a statement of agreement of the relationships and mutual respective obligations of the Island Peer Review Organization, Inc. (hereinafter referred to as "IPRO"), the Peer Review Organization ("PRO") for New York and the _________________ (hereinafter referred to as "Hospital").

STATEMENT OF GENERAL PURPOSE

This agreement is entered into with good faith and clear intent by both parties with respect to the PRO required review of services for which payment may be made in whole or in part, under Title XVIII of the Social Security Act.

In the Health Care Finance Administration (HCFA's) Sixth Scope of Work ("6th SOW") for Medicare (See Exhibit 1), HCFA continues a fundamental change, which began in the 5th SOW, in the way PROs carry out their responsibilities. The 6th SOW focuses on helping physicians and providers improve the overall care provided as well as assuring appropriate Medicare payments.

DEFINITIONS

For purposes of this agreement, the following definitions shall apply:

  1. "Act" - the Social Security Act (42 U.S.C. Chapter 7) which includes the Omnibus Budget Reconciliation Act of 1986 (OBRA) Section 9353 (c) & (e) which incorporates PRO review responsibilities in Skilled Nursing Facilities, and Home Health Agencies.
  2. "Admission Review" - review by IPRO to determine the reasonableness, medical necessity and appropriateness of a patient's admission to a hospital.
  3. "ASC" - An Ambulatory Surgical Center (ASC) is any distinct entity that:
  4. "Attending Physician" - the physician who has the responsibility for the patient's care during the course of the hospitalization.
  5. "Carrier" - party to an agreement entered into by HCFA for purpose of reimbursing Part B claims.
  6. "CDAC" - The Clinical Data Abstraction Center, under contract to HCFA and the PRO, is authorized to request medical records for abstraction and referral to HCFA and/or the PRO.
  7. "Confidential Information" - information that explicitly or implicitly identifies an individual patient, practitioner or reviewer; sanction reports and recommendations; quality review studies which identify patients, practitioners or providers; IPRO deliberations.
  8. "Critical Access Hospital (CAH)" - limited service hospitals established under Section 1820 of the Social Security Act. CAH providers must be located more than 35 miles from another hospital; have 24-hour emergency care services; no more than 15 acute care beds; and keep each inpatient for no longer than 96 hours, unless otherwise approved.
  9. "Denial Determination" - an adverse determination by IPRO based upon the lack of medical necessity, reasonableness, documentation or appropriateness of care rendered or proposed to be rendered to a beneficiary.
  10. "Department" - United States Department of Health and Human Services.
  11. "DRG" or "diagnosis related group" - Medicare classification scheme using major diagnostic categories related to major body organ systems and surgical procedures. Each PPS admission is classified into clinically meaningful groups based on patient diagnosis, procedures, age, sex, and discharge status.
  12. "Exempt Unit/Hospitals" - Where the reimbursement for care, i.e., psychiatric and/or rehabilitation services, is reimbursed on a per diem basis. Also known as non-PPS provider or unit.
  13. "Fiscal Intermediary" or "FI" - a party to an agreement entered into by HCFA for purpose of paying Part A claims.
  14. "HCFA" - Health Care Financing Administration of the Department of Health and Human Services.
  15. "HCQIP" - Health Care Quality Improvement Program - Program to develop and share with the health care community information on patterns of care and outcomes in order to improve the care for Medicare beneficiaries.
  16. "Health Care Practitioners" - those health professionals who meet all applicable State and Federal requirements for practice of their profession.
  17. "Health Care Service" - a service or item, including hospitalization, for which payment may be made (in whole or in part) under the applicable program.
  18. "HHA" - Home Health Agency - defined in Section 1861(o) of the Act as a public agency or private organization that is primarily engaged in providing skilled nursing care and other therapeutic services on an outpatient basis.
  19. "Hospital" - a health care institution or distinct part of a health care institution, as defined in Section 1861 (e) - (g) of the Act, other than a Christian Science sanatorium operated or listed and certified by a First Church of Christ Scientist, Boston, Massachusetts.
  20. "Hospital Issued Notice of Non-Coverage (HINN)" - Hospital's notice to beneficiaries of their rights when they have received a hospital inpatient discharge decision that the care is no longer needed and the patient will be financially liable.
  21. "IPRO" - the Island Peer Review Organization, Inc. authorized and empowered by its contract with HCFA to serve as the Utilization and Quality Control Peer Review Organization in New York. All references to IPRO shall include its employees and/or duly authorized agents.
  22. "MCO/M+C" - Managed Care Organization/Medicare+Choice - contractors with HCFA to provide prepaid managed care services to Medicare patients through a network of employed or affiliated providers.
  23. "Notice of Discharge and Medicare Appeals Right (NODMAR)" - (formerly Notice of Non-Coverage) - Managed Care's notice to beneficiaries of their rights when they have received a hospital inpatient discharge decision that the care is no longer needed and the patient will be financially liable.
  24. "NF" - Nursing Facility - an institution or distinct part of an institution which is primarily engaged in providing inpatient nursing care or rehabilitation services.
  25. "On-site Review" - On-site review is defined as visits to providers for the purpose of providing information and engaging in discussions with the administrative and medical staffs to aid the provider in improving their performance. Onsite review may include the review of medical records. On-site review requirements will, in general, be fulfilled by the PRO's activities as part of the HCQIP, PEPP and/or mandatory review activities.
  26. "Peer Review" - review by health care practitioner of services ordered or furnished by other health care practitioner in the same professional field.
  27. "PEPP" - Payment Error Prevention Program is intended to reduce errors associated with inpatient hospitalization. PROs will conduct activities that are to reduce the proportion of Medicare dollars paid improperly for: medically unnecessary care; inpatient care that could be provided in a more economical setting; hospital actions that circumvent Medicare rules, such as prospective payment; and, incorrect diagnostic information.
  28. "Physician" - an individual licensed as a doctor of medicine or osteopathy in the State of New York.
  29. "Physician Consultant" - a physician who is licensed in New York, who is involved in the review of cases on IPRO's behalf, and has active staff privileges in at least one hospital in the state.
  30. "PRAF" - Physician Reviewer Assessment Format - HCFA Format developed to conduct individual case review with a defined set of elements which must be collected.
  31. "Prepayment Review" - a requirement by the FI or the PRO for a review prior to reimbursement.
  32. "Proposing Physician" - the physician who proposes an admission which requires preadmission/preprocedure review.
  33. "PPS" - Prospective Payment System whereby Medicare payments for inpatient costs will be based on a pre-determined set of formulas, for each case, according to a diagnostic related group into which a case is classified.
  34. "Preadmission/Preprocedure Review" - review conducted prior to a patient's admission or surgical procedure to determine the reasonableness, medical necessity and appropriateness of health care services proposed to be delivered in that hospital or facility as well as the appropriateness of the setting.
  35. "Readmission" - an admission to a hospital occurring within thirty-one (31) calendar days of a discharge from a hospital, exclusive of day of admission and day of discharge.
  36. "Program Review Associate (PRA)/Medical Records Analyst (MRA)" - a nonphysician health care professional utilized to perform review activities. IPRO utilizes registered nurses and qualified medical records professionals (ART/RRA), experienced in utilization review and quality assurance and trained in ICD-9-CM coding.

TERM OF THE MOA

This MOA shall become effective upon its execution by both parties, and is for an initial term beginning August 1, 1999, and expiring July 31, 2002. The MOA shall be automatically renewed thereafter for consecutive annual terms unless either party, at least ninety (90) calendar days prior to the termination date, notifies the other that it intends to terminate/renegotiate this MOA, or it is otherwise terminated as provided herein. This MOA may also be terminated upon ninety (90) days prior written notice by either party.

This MOA shall terminate automatically in the event that IPRO's contract with HCFA is terminated. Notice of termination shall be in writing and sent to the other party by certified or registered mail, return receipt requested.

AMENDMENT OF THE MOA

  1. This MOA and its Amendments may be amended at any time in writing signed by both parties, provided that such amendments are in compliance with IPRO's contract with HCFA and that such amendments are consistent with pertinent statutes and regulations. The parties agree to amend this MOA to reflect statutory, regulatory and contractual changes as they may occur from time to time in the PRO program and in IPRO's contract with HCFA.
  2. Where amendments are necessary to implement statutory, regulatory and/or contractual changes, IPRO will notify the Provider Liaison by mail at least thirty (30) days prior to the effective date of the proposed amendments, provided that in those instances where mandatory changes are to become effective on issuance or prior to issuance (if less than 30 days), IPRO will notify the Provider Liaison by overnight express service or facsimile of such changes as soon as practicable.

AMENDMENT TO THE REVIEW PLANS

The Hospital will be notified, via IPRO's Medicare Administrative Memoranda Series, of any amendments to the PRO review requirements. Such notification shall make allowance for sufficient time for implementation of changes in review requests. The Hospital shall be afforded an opportunity to discuss those changes with the IPRO contact staff person identified in the Administrative Memoranda.

SCOPE OF REVIEW SERVICES TO BE PERFORMED BY IPRO

IPRO's Review Plans are included in Medicare Administrative Memoranda which are disseminated to the hospital. These memoranda describe in detail the methodology required by HCFA to conduct review activities.

  1. The following is a list of the specific review functions that are applicable to the Medicare Programs:
    1. Quality of Care/Quality Improvement Review: National and Local Projects
    2. Payment Error Prevention Program
    3. Mandatory Reviews:
      1. Review of inpatient admissions, including validations of necessity of admission, appropriateness of setting, length of stay and limitation of liability, i.e., care is not medically reasonable and necessary or is custodial.
      2. DRG/Coding Validation and DRG Adjustments: The PRO reviews hospital requested higher-weighted DRG Adjustments. (Hospitals shall submit adjustments directly to the FI for processing and payment. PRO review is post-payment.)
      3. Potential concerns identified during project data collection;
      4. Assistant at Cataract Surgery pursuant to specified codes;
      5. Review of Hospital Issued Denial Notices and NODMARs;
    4. Referrals by the FI, Carrier, OIG, HCFA, or other governmental contractors and agencies;
    5. Beneficiary Complaints/Inquiries related to quality issues and monitoring compliance with the "Important Message from Medicare" to beneficiaries;
    6. Community Outreach and Educational Programs;
    7. Anti Dumping Violations (EMTALA) and Fraud and Abuse referrals;
    8. Medicare Managed Care/Medicare+Choice.
  2. Conduct of Review
    1. Medicare review activities will be conducted at IPRO's office(s).
    2. IPRO will conduct semi-annual regional meetings for Hospital employees and medical staff to assist them in complying with the requirements of the MOA. In addition, IPRO will hold a meeting(s) with the hospital(s) related to HCQIP and PEPP activities.
    3. IPRO and/or CDAC will reimburse hospitals at the rate of $.07 per page or such other rate as may be mandated by HCFA for each record IPRO requires the hospital to copy. IPRO and/or CDAC will reimburse the Hospital for the first class mailing costs of such medical records and express mail in appropriate cases, i.e., HINN notices. IPRO and/or CDAC will reimburse the Hospital within sixty (60) days of invoice receipt, subject to receipt of such reimbursement from HCFA.

SCOPE OF HOSPITAL COOPERATION WITH REQUIRED REVIEW ACTIVITIES

  1. Both parties agree to cooperate in the implementation of peer review activities.
  2. The Hospital agrees to supply IPRO with accurate and complete medical records in accordance with the times set forth in Paragraph XI of this MOA.
  3. The Hospital agrees to provide Hospital billing data (e.g., UB-92) and other appropriate supporting documentation pertinent to cases under review upon request of IPRO within the times set forth in Paragraph XI of this MOA.
  4. When review is conducted onsite, the Hospital agrees to provide IPRO reviewers access, during the regular business hours, to its medical records for the performance of required review activities. "Access" means that the Hospital will collect and present to IPRO personnel the requested records in an orderly and timely fashion.
  5. When the review is conducted onsite, the Hospital agrees to provide reviewers with appropriate working space, including access to a telephone and within reasonable access to the Hospital's medical records for the performance of onsite review activities. Review personnel shall be permitted to use the Hospital dining and parking facilities, if available, and at IPRO's or employee's expense.

HOSPITAL NOTICES TO MEDICARE BENEFICIARIES REGARDING PRO REVIEW BY IPRO

The Hospital agrees to provide written notices to beneficiaries at the time of admission advising them of their rights as a Medicare patient and that the care for which payments is sought will be subject to PRO review by IPRO.

CONFIDENTIALITY AND DISCLOSURE OF PATIENT RECORDS AND HOSPITAL RECORDS

  1. The parties agree to comply with any confidentiality requirements applicable to utilization and quality control peer review under the Peer Review Improvement Act of 1982, and regulations promulgated thereunder. Accordingly, all information, records, and data elements collected and maintained under this MOA that pertain to practitioners, the Hospital, or beneficiaries shall be protected by the Hospital and IPRO from unauthorized disclosure as specified by the confidentiality provisions of the applicable regulations and IPRO's Confidentiality Plan.
  2. As part of its obligations, IPRO must release, upon request, data identifying individual hospitals. Any such data release by IPRO is subject to a review and comment period prior to the release by the affected hospitals. Hospital comments received will be included as part of any such release. Any data release for non-routine reports is subject to charges as determined appropriate by IPRO or required by HCFA.
  3. With regard to relationships with Regulatory Agencies, IPRO shall not release any information to other agencies unless such release is consistent with Federal law, regulation, or the Scope of Work.

IPRO REPORTS TO HOSPITALS

  1. Periodically IPRO will provide written review findings and profiles to the Provider Liaison and/or HCQIP Liaison. IPRO will work with its Provider Relations Committee toward development of reports that would be beneficial to Hospital and IPRO.
  2. Upon request of Hospital Liaison, IPRO shall produce reports based upon claims and review data. Charges for reports other than routine will vary according to the cost of additional computer and staff time required. The hospital will be informed of charges, if any, prior to preparation of any requested report.

NOTIFICATION OF REVIEW

  1. Offsite Review: IPRO shall notify the Hospital in writing specifying the records it requires to perform review offsite. The Hospital shall then have a maximum of thirty (30) calendar days to submit to the appropriate IPRO office or the CDAC the requested records. Failure of the Hospital to supply required records within the thirty (30) calendar days shall result in those cases being deemed cases for which inadequate documentation exists to support the payment claim and a "technical denial" will be issued unless extenuating circumstances exist and reasonable justification is provided.
  2. Onsite Review of Medical Records: IPRO shall notify the Hospital in writing not less than five (5) working days in advance of the review date specifying the records and data it requires for the onsite review of medical records. Additional descriptions of the time frames for review are set forth in the Administrative Memoranda disseminated to the hospital. Failure to make the requested records and data pertinent to IPRO available at the time of IPRO's visit shall result in those cases (for which records and data have not been supplied) being deemed cases for which inadequate documentation exists to support the payment and a "technical denial" will be issued after thirty (30) calendar days of the date of request for the record to be provided, unless extenuating circumstances exist and reasonable justification can be provided.
  3. If a review, referral or determination cannot be made on a claim because part of the provider medical record is illegible or physically missing, IPRO will record a documentation error for later profiling and allow the provider fifteen (15) calendar days from the date of the request to produce the record or missing portion of the record. Efforts will be made by IPRO to telephone or send a fax notification to the IPRO Liaison to request the missing information. If the requested documentation is not produced or is not legible, IPRO will issue a technical denial.

REVIEW OF HOSPITAL AND MANAGED CARE PLAN ISSUED DENIAL NOTICES (PPS AND NON-PPS HOSPITALS)

  1. IPRO review of Hospital letters denying Medicare coverage of continued inpatient hospital care (Hospital Issued Notice of Non Coverage - "HINN" and/or Notice of Discharge and Medicare Appeals Right - "NODMAR") will be performed in accordance with the HCFA PRO Manual. If the Attending Physician does not concur with the Hospital's decision, the Hospital or the Attending Physician must request IPRO review by telephone and make available all pertinent patient data, including the reason(s) for the Attending Physician's disagreement. IPRO shall make its determination and reply by telephone within two (2) working days of receipt of the medical record. If IPRO concurs with the Hospital, the notice of noncoverage will be issued by the Hospital as well as IPRO. The Hospital must supply a listing to IPRO on a monthly basis of its determinations, in a format to be distributed. In addition, Hospitals must indicate on the patient billing form all hospital issued admission and partial denials.
  2. IPRO will review those cases subject to retrospective PPS review to determine: (1) whether appropriate notice of noncoverage was given; and (2) whether such notice was valid.
  3. If IPRO detects a pattern of invalid notices of noncoverage, the corrective measures specified in the PRO Manual will be undertaken.

QUALITY IMPROVEMENT, PAYMENT ERROR, AND MANDATORY REVIEW PROCESS

Health Care Quality Improvement Program (HCQIP)

  1. IPRO will implement quality improvement projects designed to improve the quality of care of all eligible Medicare beneficiaries utilizing a standardized set of quality indicators developed by HCFA in each of the following six clinical topics: Acute Myocardial Infarction (AMI), Heart Failure, Pneumonia, Stroke/Transient Ischemic Attack/Atrial Fibrillation, Diabetes and Breast Cancer.
  2. IPRO shall also identify other quality improvement projects which will focus on specific preventive services and care processes known to improve patient outcomes, using quality indicators as measures of how often these critical processes or services are performed, or how often desired outcomes are achieved. In a quality improvement project, IPRO shall conduct analysis of data to determine whether there is an opportunity to improve care by increasing the utilization of preventive services, increasing the use of optimal care processes, and/or improving the rate of desired outcomes.
  3. Whenever possible, IPRO will coordinate its project activities with other collaborators, partners and other interested parties who may be working on comparable improvement efforts or who would be interested in teaming with IPRO. This coordination may take the form of convening meetings of interested parties, such as the New York State Department of Health, consumer groups, and business coalitions. This coordination may also include creating, joining, and/or supporting consortiums of improvement partners, etc.
  4. It is understood that HCFA reserves the right to discontinue, change, and/or add indicators for the Clinical Topics noted in 2. above, if HCFA determines it is necessary due to change(s) in clinical science.

Payment Error Prevention Program (PEPP)

  1. PEPP involves improving the claims submission process to avoid errors. Providers are required to participate in a PEPP project to insure conformance to standards of appropriate, reasonable, and medically necessary care. Claims must accurately report the diagnosis, procedures and services rendered, and beneficiary eligibility for coverage.
  2. Improvement methodologies applied to PEPP are based on monitoring and enforcing compliance with established standards.
  3. The provider may accept IPRO's technical assistance or address identified issue(s) on its own, but remeasurement by IPRO is not optional. As required by HCFA, failure to improve may have negative consequences in the form of denials/adjustments, imposition of corrective action plans, sanction recommendations, or referral to the State agency, OIG, State licensing authorities, the intermediary and/or a carrier.
  4. The Office of Inspector General has published the "OIG Compliance Program Guidance for Hospitals" (Federal Register, Vol. 63, No. 35, February 23, 1998). This publication responds to a desire on the part of providers to protect their operations from fraud and abuse through the adoption of voluntary compliance programs. While directed at tailoring programs to avoid the occurrence of fraud and abuse, such programs can also assist providers in setting up the necessary internal controls that promote adherence to applicable billing guidelines.
  5. IPRO will work with the provider/practitioner community including IPRO's Provider Relations Committee and the Criteria Norms and Standards Committee in coordinating activities related to the implementation of the PEPP Program. These committees will assist in the development of new criteria as well as updating currently utilized criteria; identifying methodologies for data analysis and profiling; and identifying best practices and interventions.

Mandatory Review

  1. The parties agree that no denial determinations shall be issued until notice of intent to issue such decision and a reasonable opportunity to discuss the decision has been provided by IPRO to the hospital and the attending physician. The IPRO Physician Consultant shall make a good faith effort to contact either in person, by telephone or in writing the Attending Physician and the hospital, where appropriate, of any proposed Utilization Review Denial Determination. IPRO shall include the opportunity for the physician and/or the provider to submit additional pertinent information. A "reasonable opportunity" shall consist of:
    1. For retrospective utilization review denials by mail - twenty (20) calendar days from the date of the notice.
    2. For expedited review of preadmission, admission and continued stay HINNs by telephone - up to twenty-four (24) hours based on timing of request.
  2. After notice and an opportunity for discussion has been provided in accordance with the above paragraph, if IPRO determines a denial shall be issued, IPRO shall give written notice of the initial Denial Determination to the patient, (excluding DRG assignment charges, denials based on circumvention of PPS, or billing errors), the Hospital Liaison, and the Fiscal Intermediary. The notice shall be delivered to the patient in the Hospital or mailed if the patient is no longer in the hospital, within the following time periods:
  3. The notice to be provided shall state the reason for denial, provide detailed documentation for the denial and advise each party of its right to request a reconsideration of the initial Denial Determination.

Quality

  1. The parties agree that the quality review process incorporated as part of mandatory review requires the PRO to issue a written notice of a "potential quality concern" to the party(ies) identified as responsible for the quality issue, and to allow a reasonable opportunity for a response. A "reasonable opportunity" shall consist of twenty (20) calendar days.
  2. The IPRO Physician Consultant shall make a good faith effort to contact either in person, by telephone, or in writing the party or parties identified as responsible for the potential quality concern.
  3. IPRO shall provide the opportunity for the party or parties identified as responsible to submit additional pertinent information during these twenty (20) days. Such notice shall be sent to the Provider Liaison and the physician. If, after the involved provider/physician has responded to IPRO, IPRO determines that the case in question contains a different potential quality concern or a different involved party, the process shall be repeated, including the allowance for twenty (20) days for provider/physician input.
  4. After notice of an opportunity for discussion has been provided in accordance with the above paragraphs, IPRO shall issue a written final quality determination.
  5. Should additional documentation or pertinent information be provided, then prior to rendering the final notice of quality concern IPRO will have the case reviewed by a second physician consultant and/or a specialist, as appropriate.
  6. A determination which confirms a quality problem shall state the reason for the final determination, and provide detailed documentation on the determination.

A determination which reverses or modifies the potential quality problem shall also be provided to the responsible party(ies) in writing.

RE-REVIEW, RECONSIDERATION AND APPEAL OF DENIAL DETERMINATIONS

Re-review

  1. Re-review is limited to two types of cases: cases where a Final Notice of Quality Concern has been sent and cases where DRG/Coding changes were made.
  2. IPRO will use a qualified physician, i.e., one in active practice in the PRO area who cares for and treats Medicare beneficiaries, (or non-physician, for technical coding issues) and appropriate reviewers, i.e., physician specialist in the area under review, in conducting re-reviews, but not the person who made the initial determination.
  3. IPRO shall send an appropriate written notice of the Re-review decision to the parties within 30 working days of the request for re-review.

Reconsideration

  1. Under Section 1155 of the SSA a Medicare beneficiary, provider or practitioner who is dissatisfied with the PRO's initial denial determination that services were not reasonable, necessary, or delivered in the appropriate setting, is entitled to a reconsideration by the PRO.
  2. The reconsideration reviewer should be a specialist in the type of services under review and not have been involved in the initial decision on the case.
  3. The reviewer reviews the medical record, any additional information or results of opportunities for discussion with the physician/provider, and makes a final determination.
  4. A written notice of IPRO's Reconsideration Determination will be sent to the parties.

Beneficiary Appeal Rights

After PRO reconsideration determinations, pursuant to the SSA and the applicable regulations, Medicare beneficiaries have the right to a hearing before an Administrative Law Judge (ALJ) and, if the jurisdictional amounts are met and the administrative remedies exhausted, a right to judicial review. (See: SSA Section 1155, 42 CFR 473.40.)

CRITICAL ACCESS HOSPITALS (CAH)

  1. Section 1820 of the Social Security Act, as amended by ?4201 of the Balanced Budget Act of 1997, established the Medicare Rural Hospital Flexibility Program. To establish a Medicare Rural Hospital Flexibility Program, each State must apply to HCFA and give specific assurances concerning the designation of CAHs and the development of at least one rural health network.
  2. A CAH must be located more than a 35-mile drive from another hospital (including another CAH). (In mountainous terrain or in areas with only secondary roads available, the mileage criterion is 15 miles.) It must have available 24-hour emergency care service, have no more than 15 acute care beds, and keep each in-patient for no longer than 96 hours, unless a longer stay is warranted because of inclement weather or other emergency conditions. An exception to the 15-bed requirement is made for swing-bed CAHs, which are allowed up to 25 inpatient beds that can be used interchangeably for acute or skilled nursing facility (SNF) level care, provided that not more than 15 beds are used at any time for acute care.
  3. A PRO may, on request, waive the 96 hour and inpatient stay restriction on a case-by-case basis. Upon request by a CAH, on a case-by-case basis, IPRO will review a CAH's Medicare 96-hour inpatient stay waiver request prior to the expiration of the 96-hour stay. The CAH must request the waiver review, by telephone, no less than five (5) hours prior to the expiration of the 96-hour limitation. Concurrently, the CAH must send IPRO a copy of the complete medical record. Upon receipt of the medical record, IPRO will review the CAH acute inpatient stay and render a determination.

WAIVER OF LIABILITY

  1. In accordance with Section 1879(a) of the Act, and 32 CFR Part 199, IPRO will determine whether the Hospital and/or beneficiary had knowledge, or should have had knowledge that certain items or services furnished during a hospital stay were excluded from coverage and/or were not medically necessary or appropriate.
  2. To receive payment under waiver, Hospital must be able to prove that it did not know or could not have been expected to know that a particular service was not reasonable and necessary or was custodial in nature. Hospital is deemed to have known that services were not covered if:
    1. the PRO, FI or Carrier had informed the Hospital that the services furnished were not covered, or that similar or reasonable comparable services were not covered;
    2. the Utilization Review Committee for the Hospital or the beneficiary's Attending Physician had informed the Hospital that these services were not covered;
    3. the Hospital had informed the beneficiary either that the beneficiary no longer required covered services or that, before services were furnished, the services were not covered;
    4. the Hospital received HCFA and/or Department of Health and Human Services notices, including manual issuances, bulletins or other written guidelines or directives from FIs, Carriers, or PROs, including notification of PRO screening criteria specific to the condition of the beneficiary for whom the furnished services are at issue or relating to medical procedures subject to Preadmission/ Preprocedure review by the PRO.
  3. On an individual case by case basis, IPRO will select or identify the following applicable limitation of liability conditions when denials are made:
    1. Beneficiary and Hospital are not liable under the limitation of liability provision of the law.
    2. Beneficiary is not liable, but the Hospital is liable under the limitation of liability provision of the law.
    3. Beneficiary is liable under the limitation of liability provision of the law (i.e., beneficiary had received prior notice for the same noncovered services; for example, a preadmission denial).
    4. Beneficiary and Hospital are liable under the limitation of liability provision of the law (i.e., hospital and beneficiary had received prior notice for the same noncovered services).
    5. The provider/beneficiary may request a reconsideration of the waiver of liability under Section 1879 of the Act (Medicare).

COOPERATION AND RESOLUTION OF ISSUES BETWEEN IPRO AND THE HOSPITAL

  1. IPRO and the Hospital agree to cooperate in the preparation and distribution of informational literature, forms, and procedures to all physicians affiliated with the Hospital. In addition, IPRO and the Hospital shall meet, as needed, upon request of either party to discuss mutual problems, evaluate procedural effectiveness, and review any other matters that may be pertinent.
  2. IPRO agrees to convene its Provider Relations Committee not less than quarterly and at more frequent intervals if either IPRO or the Committee make such a request.
  3. The Hospital shall designate an individual or individuals to be contacted by IPRO for routine inquiries and substantive issues of program relationships and developments, i.e., Provider Liaison, HCQIP Liaison and/or Compliance Liaison.
  4. IPRO shall designate an individual or individuals to be contacted by the Hospital for routine claims-related inquiries or general inquiries, quality improvement initiatives and/or regarding program relationships and developments. The names of these individuals shall be furnished to the Hospital. This information shall be updated annually and more frequently, as necessary.

HCFA RESOLUTION OF DISPUTES

In the event the Hospital and IPRO differ as to whether review activities are being carried out in accordance with this MOA, the Scope of Work, the pertinent statutory and regulatory provisions and the HCFA program directives, either party may request in writing that the contested issue be submitted to the HCFA Regional Office for resolution.

RESERVATION OF RIGHTS

No provision of this MOA shall in any way abridge or alter any right of the Hospital to challenge, through appropriate administrative or judicial appeals, legislation, regulations, adoption of policies, establishment of program directives or interpretations made by IPRO in implementing such legislation, regulations, policies or directives.

APPLICABLE LAW: SEVERABILITY

This Agreement shall be governed in all respects by the laws of the State of New York and the United States. The invalidity or unenforceability of any terms or conditions hereof shall in no way affect the validity or enforceability of any other term or provision.

ENTIRE AGREEMENT

This MOA comprises the entire agreement between IPRO and the Hospital with respect to the subject matter hereof; this MOA supersedes in its entirety all prior MOAs relating to peer review under the Medicare programs. All prior or contemporaneous written or oral agreements the Hospital may have entered into with any previous Peer Review Organization will be individually discussed, if still relevant, in order to resolve outstanding issues.

INDEPENDENT CONTRACTORS

Neither IPRO nor Hospital nor any of their respective agents, are or shall be construed as an agent or representative of the other.

IN WITNESS WHEREOF, the parties hereto have executed this Memorandum of Agreement as of the dates set forth below.

IPRO

Signature:

Theodore O. Will - Name

Executive Vice President - Title

August 1, 1999 - Date