Hospital manual.

  • United States Social Security Administration
Date:
1967]
Catalogue details

Licence: Public Domain Mark

Credit: Hospital manual. Source: Wellcome Collection.

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    pital insurance benefits. For example, if a hospital has defined extended stay as being 20 days of hospi- talization, a patient who becomes entitled to Part A benefits on May 1, but who is admitted prior to that date, would be considered as an extended-stay case for utilization review purposes on May 21. 290.2 Further Inpatient Stay Not Medically Necessary.—If in the review of an extended-stay case the physician members of the utilization review com- mittee decide, after opportunity for consultation is given the attending physician, that further inpatient stay is not medically necessary, notification in writing is given within 48 hours to the institution, the at- tending physician, and the patient. While the attend- ing physician may, if he wishes, advise the patient personally of the utilization review committee’s deci- ‘sion, it would still be necessary for the committee to give timely written notice of its decision to the patient. Payment cannot be made for more than 3 days of in- patient hospital services after the date the notice is received by the hospital. 290.3 Availability and Appropriateness of Other Facilities and Services.—In determining whether further inpatient hospital stay is medically necessary, utilization review committees are required to take. into account the availability and appropriateness of other facilities and services. The following guide- lines should be used by utilization review committees in general hospitals. (Instructions for committees in psychiatric and tuberculosis hospitals will be issued at a later date.) A. Determining Required Level of Care.—lf the committee believes that the patient no longer re- quires hospital care but could receive proper treatment in an extended care facility, it should determine whether there is a bed available to the patient in a participating extended care facility in the area (see C and E, below). If there is, the committee should find that further stay in the hospital is not medically necessary. If the committee determines that no bed is avail- able to the patient in a participating extended care facility, it should find that continued stay in the hos- pital is medically necessary. The basis for the decision _ should be documented in the committee records. The committee will advise the attending physician that its decision is based on the lack of availability of a bed in a participating extended care facility; and that it is his responsibility to attempt on a continuing basis j (with the assistance of the hospital’s social worker, etc.) to place his patient in a participating extended care facility as soon as a bed becomes available. If the utilization review committee determines that the patient requires services other than inpatient hos- pital or extended care services (such as custodial, out- patient, or home health care), it should find, without regard to the availability of such kinds of care, that further inpatient hospital stay is not medically neces- sary. Covered inpatient hospital or extended care services should not be considered as an alternative to noncovered or noninstitutional services. B. Home Health Care as an Alternative to In- stitutionalization.—A patient who needs either hos- pital or extended care services continually requires a level of care and a scope of services that can only be provided in an institutional setting. Only those institutions which meet the conditions of participation for hospitals and extended care facilities are qualified to provide them. A patient who needs home health services requires a minimal level of services which does not call for the patient to be institutionalized. For example, an in- dividual may only require a single service, such as physical therapy. A utilization review committee which finds that an individual only requires home health services should not recommend continued in- patient stay, even though the required services are not available to the individual because there is no agency in the community which can provide the services, or there is an agency but the individual has no home to which he can be discharged. C. Location of Alternative Facilities.—A utiliza- tion review committee will consider what facilities are available in the community or local geographic area in deciding whether the patient can be cared for effec- tively elsewhere. It is not possible to define com- munity or local geographic area with any precision. However, as a general rule, a community or local geographic area should not be defined in such a way as to require a patient to be taken away from his family and transported over great distances. D. Patient’s Financial Status and Personal Preference.—A utilization review committee should not take into account a patient’s ability to pay for serv- ices or his coverage or lack of coverage under the health insurance program in deciding whether con- tinued hospital stay is medically necessary. A patient’s preference for one extended care facility over another (such as a preference for a sectarian fa- cility over a nonsectarian facility) should not be taken into account by the committee. If extended care facili-
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