2023 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.