NY Pub Health L § 2803-I (2021)
2021 New York Laws PBH - Public Health Article 28 - Hospitals 2803-I - General Hospital Inpatient Discharge Review Program.

§  2803-i.  General  hospital inpatient discharge review program. 1. A general hospital inpatient discharge review program  applicable  to  all patients  other  than beneficiaries of title XVIII of the federal social security act (medicare) shall be established  in  accordance  with  this section. No general hospital inpatient subject to the provisions of this section  may  be discharged on the basis that inpatient hospital service in a general hospital is no  longer  medically  necessary  and  that  an appropriate  discharge plan has been established unless a written notice of such determinations and a  copy  of  the  discharge  plan  have  been provided  to the patient or the appointed personal representative of the patient. The patient or the appointed  personal  representative  of  the patient  shall have the opportunity to sign the notice and a copy of the discharge plan and receive  a  copy  of  both  signed  documents.  Every general hospital shall use a common notice developed and disseminated in accordance  with  rules  and  regulations  adopted  by  the  council and approved by the commissioner which shall indicate that the patient is to be discharged, shall state the reasons therefor and shall state that the patient may request a review of such determinations. The patient, or the appointed personal representative of the patient may request a review of such determinations by the appropriate independent  professional  review agent  (or  "review  agent") in accordance with subdivision four of this section. Notwithstanding  that  the  patient  discharge  review  process provided  in  accordance  with federal law and regulation shall apply to beneficiaries  of  title  XVIII  of  the  federal  social  security  act (medicare),  a  written copy of the discharge plan, and discharge notice shall  be  provided  to  the  beneficiary  or  the  appointed   personal representative  of  the  beneficiary.  The  beneficiary or the appointed personal representative of the beneficiary shall have the opportunity to sign the documents and receive a copy of the signed documents.   2. (a) For  patients  eligible  for  payments  by  state  governmental agencies  for  general  hospital  inpatient  services  as  the patient's primary payor, an independent professional review agent shall  mean  the commissioner  or  his designee. In conducting general hospital inpatient discharge reviews in accordance with this section, the commissioner  may utilize  the  services  of  department  personnel  or  other  authorized representatives, including a review agent approved  in  accordance  with paragraph (b) of this subdivision.  (b)  For  patients  who  are  not  beneficiaries of title XVIII of the federal social security act (medicare)  nor  eligible  for  payments  by state   governmental   agencies  as  the  patient's  primary  payor,  an independent professional review agent shall mean a third party payor  of hospital  services  or other corporation approved by the commissioner in writing for purposes of conducting general hospital inpatient  discharge reviews  in  accordance  with  this  section. For a third party payor of hospital services or other corporation to be approved as an  independent professional  review agent in accordance with this paragraph, such third party payor or other corporation must meet the following  criteria:  (i) the  review  agent  shall  employ  or  otherwise  secure the services of adequate medical personnel  qualified  to  determine  the  necessity  of continued   inpatient  hospital  services  and  the  appropriateness  of hospital discharge plans; (ii) the review agent  shall  demonstrate  the ability  to  render  review  decisions in a timely manner as provided in this section; (iii) the review agent shall agree to provide ready access by the commissioner to all data, records and information it collects and maintains concerning its review activities under this section; (iv)  the review  agent  shall  agree  to  provide  to the commissioner such data, information and reports as  the  commissioner  determines  necessary  to evaluate  the  review process provided pursuant to this section; (v) the  review agent shall provide assurances that review  personnel  shall  not have  a  conflict  of  interest  in  conducting a discharge review for a patient based on hospital or  professional  affiliation;  and  (vi)  the review  agent  meets  such  other  performance  and  efficiency criteria regarding the conduct of reviews pursuant to this section established by the  commissioner.  The  commissioner  may  withdraw  approval   of   an independent  professional  review agent where such review agent fails to continue  to  meet  approval  criteria  established  pursuant  to   this paragraph.  (c)  (i)  Each general hospital shall enter into contracts with one or more independent professional review agents approved by the commissioner in accordance with paragraph (b) of this  subdivision  for  purposes  of conducting  general  hospital  inpatient discharge reviews in accordance with this section for patients, including uncompensated  care  patients, who  are not beneficiaries of title XVIII of the federal social security act (medicare) nor eligible for payments by state governmental  agencies as  the  patients' primary payor; provided, however, a payor of hospital service included in the payor categories specified in paragraph  (a)  of subdivision one of section twenty-eight hundred seven-c of this article, other  than  state governmental agencies, may designate the review agent for their subscribers or beneficiaries or  enrolled  members  and  shall reimburse such designated review agent for costs of the discharge review program.  (ii)  Notwithstanding  any  inconsistent  provision  of  law,  general hospital contract costs incurred in accordance with subparagraph (i)  of this  paragraph  may  be  included  as  an additional charge for general hospital inpatient services in determining patient  charges  for  payors included   in  the  payor  categories  specified  in  paragraph  (c)  of subdivision one of section twenty-eight hundred seven-c of this article, or as a charge in addition to rates  of  payment  for  general  hospital inpatient services in determining payment due for payors included in the payor  categories  specified  in  paragraph  (b)  of  subdivision one of section twenty-eight hundred seven-c of this article, or  paragraph  (a) of such subdivision one if a payor has not designated a review agent for such  payor's  subscribers  or  beneficiaries  or  enrolled  members, or paragraph (a) or (b) of subdivision two of section twenty-eight  hundred seven-c of this article. Such additional charges shall not be subject to maximum charge or rate of payment ceilings determined in accordance with section twenty-eight hundred seven-c of this article for such payors.   3.  (a)  If  a general hospital and the attending physician agree that inpatient hospital service in a general hospital is no longer  medically necessary  for a patient, other than a beneficiary of title XVIII of the federal social security act (medicare),  and  an  appropriate  discharge plan  has  been  established for such patient, at that time the hospital shall provide the patient or the appointed  personal  representative  of the  patient with a written discharge notice and a copy of the discharge plan, meeting the requirements of subdivision one of this section.  (b) If a general  hospital  has  determined  that  inpatient  hospital service  in  a  general  hospital is no longer medically necessary for a patient, other than a beneficiary of title XVIII of the  federal  social security  act  (medicare),  and  an  appropriate discharge plan has been established for such patient but the attending physician has not  agreed with   the  hospital's  determinations,  the  hospital  may  request  by telephone a review of the validity of the hospital's  determinations  by the appropriate independent professional review agent. Such review agent shall conduct a review of the hospital's determinations and prior to the conclusion  of  the  review shall provide an opportunity to the treating physician and an appropriate representative of the  hospital  to  confer  and provide information which may include the patient's clinical records if  requested  by  the  review agent. Such review agent shall notify the hospital of the results of its review not later  than  one  working  day after  the  date  the review agent has received the request, the records required to conduct such review, and the date  of  such  conferring  and receipt  of  any  additional  information  requested. The hospital shall provide notice to the attending physician of the results of the  review. If  the  review  agent  concurs  with the hospital's determinations, the hospital  shall  provide  the  patient   or   his   appointed   personal representative  with  a written notice of such determinations and notice that the patient shall be financially responsible  for  continued  stay, and  with  a  copy  of  the  proposed discharge plan. The patient or the appointed  personal  representative  of  the  patient  shall  have   the opportunity to sign the notice and a copy of the proposed discharge plan and  receive  a  copy  of  both signed documents. Every general hospital shall use a common notice developed and disseminated in accordance  with rules  and  regulations  adopted  by  the  council  and  approved by the commissioner which shall indicate the determinations made,  shall  state the  reasons  therefor  and  that  the patient's attending physician has disagreed and shall state that the patient  or  the  appointed  personal representative   of   the   patient   may   request  a  review  of  such determinations by the appropriate review agent.   4. A  patient  in  a  general  hospital,  or  the  appointed  personal representative  of  the  patient,  who  receives  a  written  notice  in accordance with paragraph (a)  or  (b)  of  subdivision  three  of  this section,  may  request  a  review by the appropriate review agent of the determinations set forth in such notice related to medical necessity  of continued   inpatient  hospital  service,  the  appropriateness  of  the discharge plan and the availability of required continuing  health  care services.  (a)  If  a  patient  while  still  hospitalized  or while no longer an inpatient, or the appointed personal  representative  of  such  patient, requests  a  review  by the appropriate review agent, the hospital shall promptly provide to the review agent the records required to review  the determinations.  Such request for a patient no longer an inpatient shall take place no later than thirty days after receipt of a notice  provided in accordance with subdivision three of this section or seven days after receipt  of  a  complete  bill  for  all  inpatient  services  rendered, whichever is later. The review agent shall  conduct  a  review  of  such determinations   and   shall  provide  the  treating  physician  and  an appropriate representative of the hospital with an opportunity to confer and provide information prior to  the  conclusion  of  the  review.  The review  agent  shall  provide  written  notice  to  the  patient, or the appointed personal representative of the patient, and  the  hospital  of the  results  of  the review within three working days of receipt of the requests  for  review  and  the   records   required   to   review   the determinations.  The  hospital  shall  provide  notice  to the attending physician of the results of the review.  (b)  Notwithstanding  the  provisions  of  paragraph   (a)   of   this subdivision,  if  a  patient  while  still  an  inpatient in the general hospital, or the  appointed  personal  representative  of  the  patient, requests a review by the appropriate review agent not later than noon of the  first  working  day  after  the  date the patient, or the appointed personal representative of the patient, receives the written notice, the hospital shall provide to  the  appropriate  review  agent  the  records required  to  review the determinations by the close of business of such working day. The appropriate review agent shall conduct a review of such determinations and  provide  written  notice  to  the  patient,  or  the  appointed  personal  representative  of the patient, and the hospital of the results of the review not later than one full working day after  the date  the  review  agent  has  received  the request for review and such records. The hospital shall provide notice to the attending physician of the results of the review.   5.   Notwithstanding   any  inconsistent  provision  of  law,  if  the appropriate  review  agent,  upon  any  review  conducted  pursuant   to paragraph  (b)  of  subdivision three or pursuant to subdivision four of this section does not concur in the determinations, continued stay in  a general  hospital  shall  be  deemed  necessary  and appropriate for the patient for purposes of payment for such continued  stay  in  accordance with section twenty-eight hundred seven-c of this article.   6.  If  a patient eligible for payment for inpatient hospital services under a case based payment per discharge determined in  accordance  with section  twenty-eight  hundred seven-c of this article, or the appointed personal representative  of  the  patient,  requests  a  review  by  the appropriate review agent in accordance with paragraph (b) of subdivision four of this section, the hospital may not demand or request any payment for  additional  inpatient  hospital  services  provided to such patient subsequent to the proposed time of discharge and prior to  noon  of  the day  after the date the patient or the appointed personal representative of the patient receives notice of the  results  of  the  review  by  the review  agent  other  than payment determined in accordance with section twenty-eight  hundred  seven-c  of   this   article   and   deductibles, copayments,  or other charges that would be authorized for a patient for whom inpatient hospital services in a general hospital  continue  to  be necessary and appropriate.   7.  In  any  review conducted pursuant to paragraph (b) of subdivision three or pursuant to subdivision four of this section, the review  agent shall  solicit  the  views  of  the  patient  involved, or the appointed personal representative of the patient, and the attending physician.   8. Each patient, or  the  appointed  personal  representative  of  the patient,  provided  a  notice  by  a general hospital in accordance with subdivision three of this section shall be provided at such time by  the hospital with a notice, in a form developed in accordance with rules and regulations  adopted by the council and approved by the commissioner, of such patient's right to request a discharge review  in  accordance  with this  section.  The  patient or the appointed personal representative of the patient shall have the opportunity to sign this form and  receive  a copy of the signed form.   9.  Upon discharge of a blind or visually impaired patient, a hospital shall offer to provide the patient's discharge plan  in  a  large  print version  or,  at the patient's or patient's representative's request, as an audio recording, to  be  made  available  to  such  patient  or  such patient's representative on compact disc or other medium as the hospital may offer, or as an electronically transmitted digital file, in addition to a written copy of the discharge plan.   10.  The  council  shall  adopt  rules and regulations, subject to the approval of the commissioner, necessary to implement this section.