Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 27 - Utilization Review Procedures › Section I-2707 - Admission and Continued Stay Review

Current through Register Vol. 50, No. 6, June 20, 2024
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.