Effective for dates of discharge on or after July 1,
2014:
a) Utilization Review
The Department, or its designated peer review organization,
shall conduct utilization review in compliance with Section 1152 of the Social
Security Act and 42 CFR Subchapter F (October 1, 2013). A peer review shall be
conducted by a Physician Peer Reviewer who is licensed to practice medicine in
all its branches, engaged in the active practice of medicine, board certified
or board eligible in his or her specialty and has admitting privileges in one
or more Illinois hospitals. Payment will only be made for those admissions and
days approved by the Department or its designated peer review organization.
Utilization review may consist of, but not be limited to, preadmission,
concurrent, pre-payment, and post-payment reviews to determine, pursuant to 42
CFR 476, Subpart C (October 1, 2013), the following:
1) Whether the services are or were
reasonable and medically necessary for the diagnosis and treatment of illness
or injury;
2) The medical
necessity, reasonableness and appropriateness of hospital admissions and
discharges, including, but not limited to, the coordination of care
requirements defined in Section
148.40(a)(10)
for the Children's Mental Health Screening,
Assessment and Support Services (SASS) Program;
3) Through DRG validation, the validity of
diagnostic and procedural information supplied by the hospital;
4) The completeness, adequacy and quality of
hospital care provided;
5) Whether
the quality of the services meets professionally recognized standards of health
care; or
6) Whether those services
furnished or proposed to be furnished on an inpatient basis could, consistent
with the provisions of appropriate medical care, be effectively furnished more
economically on an outpatient basis or in an inpatient health care facility of
a different type.
b)
Notice of Utilization Review
The Department shall provide hospitals with notice 30 days
before a service is subject to utilization review, as described in subsections
(c), (d), (e) and (f) of this Section, that the service is subject to such
review. In determining whether a particular service is subject to utilization
review, the Department may consider factors that include:
1) Assessment of appropriate level of
care;
2) The service could be
furnished more economically on an outpatient basis;
3) The inpatient hospital stays for the
service deviate from the norm for inpatient stays using accepted length of stay
criteria;
4) The cost of care for
the service;
5) Denial rates;
and
6) Trends or patterns that
indicate potential for abuse.
c) Preadmission Review
Preadmission review may be conducted prior to admission to a
hospital to determine if the services are appropriate for an inpatient setting.
The Department shall provide hospitals with notice of the criteria used to
determine medical necessity in preadmission reviews 30 days before a service is
subject to preadmission review.
d) Concurrent Review
Concurrent review consists of a certification of admission
and, if applicable, a continued stay review.
1) The certification of admission is
performed to determine the medical necessity of the admission and to assign an
initial length of stay based on the criteria for the admission. Admissions will
be denied for patients 21 years of age or over who present at a hospital within
60 days after a previous admission for specified alcohol-induced or
drug-induced detoxification. The Department will specify to hospitals the lists
of affected diagnosis codes via provider releases and postings on the
Department's website.
2) The
continued stay review is conducted to determine the medical necessity and
appropriateness of continuing the inpatient hospitalization. More than one
continued stay review can be performed in an inpatient stay.
e) Pre-payment Review
The Department may require hospitals to submit claims to the
Department for pre-payment review and approval prior to rendering payment for
services provided.
f)
Post-payment Review
Post-payment review shall be conducted on a random sample of
hospital stays following reimbursement to the hospital for the care provided.
The Department may also conduct post-payment review on specific types of
care.
g) Hospital
Utilization Control
Hospitals and distinct part units that participate in
Medicare (Title XVIII) must use the same utilization review standards and
procedures and review committee for Medicaid as they use for Medicare.
Hospitals and distinct part units that do not participate in Medicare must meet
the utilization review plan requirements in 42 CFR 456 (October 1, 2013).
Utilization control requirements for inpatient psychiatric hospital care in a
psychiatric hospital, as defined in 89 Ill. Adm. Code
148.25(d)(1)
shall be in accordance with the federal
regulations.
h) Denial of
Payment as a Result of Utilization Review
1)
If the Department determines, as a result of utilization review, that a
hospital has misrepresented admissions, length of stay, discharges, or billing
information, or has taken an action that results in the unnecessary admission
or inappropriate discharge of a program participant, unnecessary multiple
admissions of a program participant, unnecessary transfer of a program
participant, or other inappropriate medical or other practices with respect to
program participants or billing for services furnished to program participants,
the Department may, as appropriate:
A) Deny
payment (in whole or in part) with respect to inpatient hospital services
provided with respect to such an unnecessary admission, inappropriate length of
stay or discharge, subsequent readmission, transfer of an individual or failure
to comply with the coordination of care requirements of Section
148.40.
B) Require the hospital to
take action necessary to prevent or correct the inappropriate
practice.
2) When
payment with respect to the discharge of an individual patient is denied by the
Department or its designated peer review organization, under subsection
(h)(1)(A) as a result of prepayment review, a reconsideration will be provided
within 30 days upon the request of a hospital or physician if such request is
the result of a medical necessity or appropriateness of care denial
determination and is received within 60 days after receipt of the notice of
denial. The date of the notice of denial is counted as day one.
3) When payment with respect to the discharge
of an individual patient is denied by the Department or its designated peer
review organization under subsection (h)(1)(A) as a result of a preadmission or
concurrent review, the hospital or physician may request an expedited
reconsideration. The request for expedited reconsideration must include all the
information, including the medical record, needed for the Department or its
designated peer review organization to make its determination. A determination
on an expedited reconsideration request shall be completed within one business
day after the Department's or its designated peer review organization's receipt
of the request. Failure of the hospital or physician to submit all needed
information shall toll the time in which the reconsideration shall be
completed. The results of the expedited reconsideration shall be communicated
to the hospital by telephone within one business day and in writing within
three business days after the determination.
4) A determination under subsection (h)(1),
if it is related to a pattern of inappropriate admissions, length of stay and
billing practices that has the effect of circumventing the prospective payment
system, may result in:
A) Withholding payment
(in full or in part) to the hospital until the hospital provides adequate
assurances of compliance; or
B)
Termination of the hospital's Provider Agreement.
i) Furnishing of Inpatient
Hospital Services Directly or Under Other Arrangements
1) The applicable payments made under this
Part and 89 Ill. Adm. Code
149 are payment in full for all inpatient hospital
services other than for the services of nonhospital-based physicians to
individual program participants and the services of certain hospital-based
physicians as described in subsections (i)(1)(B)(i) through (i)(1)(B)(v).
A) Hospital-based physicians who may not bill
separately on a fee-for-service basis:
i) A
physician whose salary is included in the hospital's cost report for direct
patient care.
ii) A teaching
physician who provides direct patient care, if the salary paid to the teaching
physician by the hospital or other institution includes a component for
treatment services.
B)
Hospital-based physicians who may bill separately on a fee-for-service basis:
i) A physician whose salary is not included
in the hospital's cost report for direct patient care.
ii) A teaching physician who provides direct
patient care, if the salary paid to the teaching physician by the hospital or
other institution does not include a component for treatment
services.
iii) A resident, when, by
the terms of his or her contract with the hospital, he or she is permitted to
and does bill private patients and collect and retain the payments received for
those services.
iv) A
hospital-based specialist who is salaried, with the cost of his or her services
included in the hospital reimbursement costs, when, by the terms of his or her
contract with the hospital, he or she may charge for professional services and
does, in fact, bill private patients and collect and retain the payments
received.
v) A physician holding a
nonteaching administrative or staff position in a hospital or medical school,
to the extent that he or she maintains a private practice and bills private
patients and collects and retains payments made.
2) Charges are to be submitted on
a fee-for-service basis only when the physician seeking reimbursement has been
personally involved in the services being provided. In the case of surgery, it
means presence in the operating room, performing or supervising the major
phases of the operation, with full and immediate responsibility for all actions
performed as a part of the surgical treatment.
j) "Designated peer review organization"
means an organization designated by the Department that is experienced in
utilization review and quality assurance, which meets the guidelines in Section
1152 of the Social Security Act and 42 CFR 475(2013).
