Medicare (Title XVIII of the Social Security Act)
Hospitals

Hospitals14

Providers15 of inpatient hospital services must certify the beneficiary’s need for such services16 and must periodically provide materials for recertification in accordance with regulations.17

Hospitals,18 including psychiatric hospitals,19 must implement the following:

·        A utilization review plan20 that includes the following:

o       Review of admissions to the institution;

o       Review of the duration of stays in the institution;

o       Review of the medical necessity of the professional service furnished;21  and

o       Provision for prompt notification to the institution, the individual and his attending physician of a finding that further stay in the institution is not medically necessary.22

·        A discharge planning process23 that includes:

o       Early identification of patients likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning;24

o       Discharge planning evaluations for such patients and for other patients upon request;25

o       Evaluation of a patient’s likely need for appropriate post-hospital services;26

o       Inclusion of the discharge planning evaluation in the patient’s medical record for use in establishing an appropriate discharge plan; and

o       Provision for the discussion of the results of the evaluation with the patient or his representative.27

Long-term care hospitals must have a patient review process that:

·      Is documented in the patient’s medical record

·      Screens patients prior to admission for appropriateness of admission

·      Validates within 48 hours of admission that patient meets admission criteria,

·      Regularly evaluates patients throughout their stay for continuation of care, and

·      Assesses the available discharge options when patients no longer meet such continued stay criteria.28

Long-term care hospitals must have an interdisciplinary team of health professionals, including physicians, prepare individualized treatment plans for each patient.29

All hospitals, including critical access hospitals must adopt and enforce a policy to ensure compliance with § 186730 and must maintain medical and other records related to individuals transferred to or from the hospital for a period of five years after the date of transfer.31

If, after being informed of the risks and benefits by the hospital, an individual refuses to consent to examination and treatment or to transfer to another medical facility, the hospital shall take all reasonable steps to secure the individual’s written consent to refuse examination, treatment32 or transfer.33  If an individual at a hospital has an emergency medical condition that has not been stabilized, the hospital may not transfer the individual unless, after being informed of the risk of the transfer, the individual in writing requests transfer34 and a physician has signed a certification that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual, and in the case of labor, to the unborn child from effecting the transfer.35  An appropriate transfer is one in which the transferring hospital sends to the receiving facility all medical records, or copies thereof available at the time of transfer, related to the emergency condition for which the individual has presented, including records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, and the results of any tests.36

In considering allegations of violations of the requirements of this section, the Secretary37 will request the appropriate utilization and quality control peer review organization to assess whether the individual involved had an emergency medical condition which had not been stabilized, and provide a report on its findings.38  The Secretary will provide a copy of the organization’s report to the hospital or physician consistent with confidentiality requirements imposed on the organization.39