La. Admin. Code tit. 40 § I-2707

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-2707 - Admission and Continued Stay Review

A. In those instances when an emergency hospital admission is involved, an admission review is conducted. Admission review determines the medical appropriateness of the admission and utilizes the same techniques employed in pre-admission certification review such as reviewing all pertinent medical information against a set of accepted medical criteria to evaluate the need for hospital level of care. Non-emergency admissions that have not been pre-certified by pre-admission certification review are also monitored through admission review. If the admission is considered appropriate, a reasonable length of stay is assigned using a set of standard criteria. The admission review and continued stay review follow the sequence below.

B. Continued stay review is the review of the appropriateness and necessity of continued hospitalization while the patient is still in the hospital. The review is conducted using acceptable medical criteria to evaluate the appropriateness of continued hospital level of care. The same criteria used in pre-admission certification review are used during continued stay review. The day before the expected discharge date, the case is reviewed to determine if hospital level of care is still needed. If additional inpatient care is necessary, review personnel will authorize an extension of the length of stay.

C. Continued stay review is an integral part of managed care. During continued stay review, review personnel can identify cases that will benefit from individual case management. Continued stay review permits the review personnel to become aware of changes in a patient's condition or slow recovery which may necessitate a longer hospital stay.

D. Admission and Continued Stay Review Procedures

1. The carrier/self-insured employer will automatically review the necessity for continued hospitalization the day before the initial length of stay assigned expires without claimant initiation responsibility. The responsibility to request an extension may be delegated to the hospital if requested by the hospital and agreed to in writing by the carrier/self-insured employer. If the party who has the responsibility for initiating the continued stay review fails to do so, they will be responsible for the cost of any subsequent care provided.

2. Continued stay review will include telephone discussions with the hospital or physician if the information required is not available from the hospital. All pertinent information necessary to determine if continued hospitalization is medically necessary and appropriate will be gathered (i.e., current medications and methods of administration used, frequency, lab values, and results of diagnostic tests). If re-certification is appropriate, additional days are assigned based upon statistical norms indicated in the PAS manual using the next higher percentile adjusted by the medical judgement of the reviewer, if applicable. This process will continue until the patient is discharged or until documentation no longer supports the medical necessity for inpatient services. If re-certification is not medically necessary or appropriate based upon documentation reviewed, the medical director will issue a denial to the physician, claimant, and hospital by the close of business (4:30 p.m. Central Time) on the day of the review.

3. All nonelective acute care hospital admissions including emergencies, psychiatric admissions, and all extended hospitalizations are reviewed using nationally accepted criteria designed to assess the need for hospital level of care. The Appropriateness Evaluation Protocol (AEP) and the Intensity/Severity/Discharge (ISD) criteria are the two most prominent nationally accepted criteria for admissions.

4. Automated software support for the review process is recommended in order to assure timely responses, uniform administration and complete data gathering. Computer prompts may be especially important in following up on length of stay assignments and assuring timely continued stay review.

5. Registered nurses use written criteria to assess the need for continued stays in the hospital. Physicians review all questionable cases and will make the final carrier/self-insured employer decisions on all denials of certification.

6.

a. An appeals process must be available for reconsideration of any denial decisions. If the admitting/treating physician, hospital, or claimant desires to appeal a denial of an admission or continued stay request, the appeals process is initiated by contacting the carrier/self-insured employer by telephone or other immediate means following receipt of the denial. After the appeal request is received, it will be referred to the carrier/self-insured employer medical director or physician consultant. The carrier/self-insured employer medical director or physician consultant will review the available information regarding the request and make a decision concerning the appeal within 48 hours of receipt/communication of the appeal.

b. If the carrier/self-insured employer medical director's decision is an approval of the appeal the admitting/treating physician and hospital will be immediately notified via telephone and follow up by letter will be sent to the physician, claimant, and hospital.

c. If the carrier/self-insured employer medical director's decision is a denial the carrier/self-insured employer will notify the admitting/treating physician and hospital and will immediately submit in writing the denial and case documentation by fax to the director of the Office of Workers' Compensation for review at (225) 342-6556.** The material should be clearly identified as a denial of an admission or continued hospital stay request and should be addressed "Attention: Medical Manager, Office of Workers' Compensation." The director will immediately review the case and will notify the carrier/self-insured employer, the admitting/treating physician, and hospital by telephone of his agreement or disagreement with the denial decision. Follow-up notification will be sent to the claimant, carrier/self-insured employer, hospital, and admitting/treating physician by certified mail return receipt requested. Any party who disagrees with the director's resolution may file a Disputed Claim for Compensation Form (LDOL-WC-1008), available from the Office of Workers' Compensation Administration as otherwise provided by law.

7. The review process is also used to identify and refer cases for discharge planning.

8. The program includes written notification of the continued stay review decision to the claimant, physician and the hospital.

9. The carrier/self-insured employer maintains appropriate internal documentation of each request for continued stay review to verify the process and the decision for claims processing and reporting purposes.

E. Admission And Continued Stay Review Preparation

1. Preparation

a. Educational Program for Providers. The carrier/self-insured employer will maintain and make available to the provider information regarding the admission and continued stay review certification program, describing the reasons for implementation and operation, including an explanation of the appeals process. This notice of the admission and continued stay review program may be included in local carrier/self-insured employer provider newsletters.

b. Admission and Continued Stay Review Forms. The carrier/self-insured employer may use samples (Exhibit 1 and 2, Clauses E.1.d.i and ii) or develop forms to capture pertinent patient and provider information during the admission and continued stay review activity. These forms may be identical to those used by the carrier/self-insured employer for their other business, however, they should capture the statistical data elements required by the Office of Workers' Compensation Administration.

c. Standardized Form Letters. The carrier/self-insured employer will develop letters announcing the results of the admission and continued stay review process to:

i. claimant;

ii. the admitting/treating physician; and

iii. the hospital, with appeals process information where necessary.

d. Exhibits of Form Letters

i. Exhibit 3-A-Continued Stay Approval Letter

Re: Patient: Pre-Admission Certification No.: Claimant No.: Date of Service: Hospital: Additional days to the hospital referenced above have been approved based upon a determination of medical necessity for continued inpatient care. A total of (indicate number of days) days is available for this hospital stay. it is important for you to know that ... This approval of the inpatient hospital setting is based on information provided by the above listed hospital and/or physician. the determination of actual benefits ... Can only be made upon receipt of completed claim. Payment for the services received is subject to statutory limitations. Eligibility is dependent upon: 1. the medical necessity for the services provided; and 2. the work-relatedness of the illness or injury. if the claimant requires continued hospitalization beyond the number of days approved ... The admitting physician or authorized hospital representative should contact the carrier/self-insured employer at (phone number) on or before the above days expire. benefits for services rendered during additional hospital days not certified may be denied.

ii. Exhibit 3-C-Continued Stay Denial Letter

Re: Patient: Pre-Certification No.: Contract No.: Date of Service: Hospital: Dear (claimant/physician/provider) The medical director has reviewed carefully your current medical status and, based upon the information obtained, has determined that the medical necessity of further hospitalization has not been documented. Charges for inpatient services after (date), at the hospital referenced above will not be considered for payment. If you disagree with this decision, you may appeal in accordance with the guidelines attached. Sincerely,

2. Implementation

a. Telephone Inquiry Service. Telephone numbers should be published in educational materials and standardized form letters to the physicians, hospitals, and claimants. This telephone service allows for prompt response to requests for review and to general inquires about the review process.

b. Appropriate Staff and Documentation for Program Management of Certified, Denied, and Appealed Admissions. Registered nurses and physicians are the recommended staff for processing of admission and continued stay review requests and inquires. Procedures must be available for timely review of appealed or denied admissions by a physician (a psychiatrist for mental illness or substance abuse admissions). Program procedures should be routine and documented.

3. Evaluation

a. Data Collection. Admission and continued stay review documentation should be linked to the claims system to properly process inpatient claims. The admission and continued stay review documentation should be retrievable on a claim-by-claim basis for compilation and classification of activity performance.

b. Carrier/Self-Insured Employer Data Reporting. Carrier/self-insured employer will be required to collect data according to the Office of Workers' Compensation Administration requirements:

Information	Positions	Type
ICD-10-CM	5/7	Numeric
Provider Name	30	Alpha
Provider Street Address	30	Alpha Numeric
Parish Code for Provider of Service (Use Standard FIPS code, see Exhibit 5)	3	Numeric
Place of Treatment	1	Alpha Numeric
Type of Facility*	6	Numeric

Type of Service: Medical vs. Surgical	1	Alpha Numeric
Claimant Name	30	Alpha
Claimant Social Security Number	9	Numeric
Length of Stay	4	Numeric
* See "Type Facility Codes" in Exhibit 6.

La. Admin. Code tit. 40, § I-2707

Promulgated by the Department of Employment and Training, Office of Workers' Compensation, LR 17:263 (March 1991), repromulgated LR 17:653 (July 1991), Amended by the Workforce Commission, Office of Workers' Compensation Administration, LR 42284 (2/1/2016).

The telephone number for the Office of Workers' Compensation has been changed to (225) 342-7555.**

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1291.