COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HUMAN SERVICES
PROVIDER NAME/ADDRESS:Albert Einstein Medical Center
5501 Old York Road
Philadelphia, PA 19141 / PROVIDER’S REPRESENTATIVE
Erica Belton, M.D.
Medical Director,
Care Management / PROVIDER’S WITNESS (ES)
RECIPIENTS INVOLVED:
Shirley Marlow
DOS: 5/3/14 - 5/5/14 / DEPARTMENT REPRESENTATIVE
Barry Wingard, M.D.
Contracted Medical Director,
OMAP/Bureau of Fee for Service Programs / DEPARTMENT WITNESS(ES)
CASE #
51X0727-001 / BHA ID NUMBER/BHA DOCKET NUMBERS/ISSUE CODES
Cert # 1419510026 Issue Code: 920
DATE ADVERSE ACTION MAILED
8/27/2014 / DATE APPEAL RECEIVED
POSTMARKED AT DPW / DATE APPEAL RECEIVED
AT BHA
9/26/2014 / IR DUE DATE
3/25/2015
DATE SCHEDULING NOTICE MAILED
2/3/2015 / RESCHEDULED TO / DATE OF HEARING
2/23/2015 / START TIME
1:06 PM
END TIME
1:36 PM
HEARING LOCATION
Philadelphia, PA / TELEPHONE FACE TO FACE OTHER
ORDER
AND NOW, after careful review and consideration of the Recommendation of the Administrative Law Judge, it is hereby ORDERED that the Recommendation be adopted in its entirety.
Either party to this proceeding has thirty (30) calendar days from the date of this decision to request reconsideration by the Secretary of the Department. To seek reconsideration, you must fully complete the enclosed application/petition for reconsideration. The application/petition shall be addressed to the Secretary, but delivered to the Director, Bureau of Hearings and Appeals, P.O. Box 2675, Harrisburg, Pennsylvania, 17105-2675, and must be received in the Bureau of Hearings and Appeals within thirty (30) calendar days from the date of this Order. This action does not stop the time within which an appeal must be filed to Commonwealth Court. The applicant/petitioner shall serve a copy of the application/petition for reconsideration on the opposing party(ies).
The appropriate party(ies), where permitted, may take issue with this Adjudication, and Order, and may appeal to the Commonwealth Court of Pennsylvania, within thirty (30) days from the date of this order. This appeal must be filed with the Clerk of Commonwealth Court of Pennsylvania, 601 Commonwealth Avenue, Suite 2100, P.O. Box 69185, Harrisburg, Pennsylvania17106-9185.
If you file an appeal with the Commonwealth Court, a copy of the appeal must be served on the government unit which made the determination in accordance with Pa. R.A.P. 1514. In this case, service must be made to: Department of HumanServices, Bureau of Hearings and Appeals, 2330 Vartan Way, 2nd Floor, Harrisburg, Pennsylvania 17110-9721, ANDDepartment of HumanServices, Office of General Counsel, 3rd Floor West, Health & Welfare Building, Harrisburg, PA 17120.
Bureau of Hearings and AppealsFinal Administrative Action and Mailing Date
6/18/2015 /
Tracy L. Henry, Esquire Chief Administrative Law Judge
cc:
Albert Einstein Medical Center
Attn: Erica Belton, MD
DHS/OMAP/DMR/BFFS
Recipient Appeals Section
PO Box 8050
Harrisburg PA 17105
Barry A. Wingard, MD
Charlene Petrone
Susan Bathurst
File
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HUMAN SERVICES
APPEAL OF: Albert Einstein Medical Center
5501 Old York Road
Philadelphia, PA 19141
CASE NO. 51X0727-001
RECOMMENDATION
It is hereby Recommended that the appeal of the Appellant bedenied.
June 18, 2015
Date Administrative Law Judge
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HUMAN SERVICES
BUREAU OF HEARINGS AND APPEALS
APPEAL OF: Albert Einstein Medical Center
5501 Old York Road
Philadelphia, PA 19141
CASE NO. 51X0727-001
ADJUDICATION
OPENING STATEMENT
This is an administrative adjudication on the appeal of Albert Einstein Medical Center (Appellant) from a determination by the Department of Human Services, Office of Medical Assistance Programs (Department). A telephone hearing was convened from 1:06PM to 1:36 PM on February 23, 2015, from the Bureau of Hearings and Appeals in Philadelphia, PA. All witnesses were sworn in by the undersigned and testified under oath.
Roseann Kelly, Administrative Law Judge (ALJ), presided.
EXHIBITS
For the Department:
C-1 Curriculum Vitae for Barry A. Wingard, MD, MS, FACS (2 pages)
C-2Regulations from 55 Pa. Code, Medical Assistance Bulletin 01-98-14, and
InterQualAcute Adult Criteria for COPD (50pages)
C-3Excerpt from themedical record, including the Discharge Summary (4 pages)
C-4Notice of Decision dated August 27, 2014, Appeal Letter, and InterQual Review Summary (4 pages)
For the Appellant:
A-1Curriculum Vitae for Erica M. Belton, MD (5 pages)
A-2Excerpt from themedical record regarding: Admission History and Physical Examination(2 pages)
A-3Progress Notes (2) and excerpt from the Admission and Physical Examination dated May 3, 2014, 10:30 PM. (4 pages)
A-4Discharge Summary (3 pages)
ISSUE
Whether the Department correctly denied the Appellant’s request for reimbursement for the Patient’s inpatient admission ofMay 3, 2014 to May 5, 2014,because inpatient admission was not medically necessary.
FINDINGS OF FACT
- On May 3, 2014, the Patient, a sixty four(64) year old female,presented to the Appellant’s Emergency Room (ER)via ambulance at 6:47 PM,forshortness of breath that had lasted for the past two days, and a cough. (ExhibitA-3)
- The Patient had a past medical history whichincluded Chronic Obstructive Pulmonary Disease (COPD), hypertension, and Type 2 Diabetes. (ExhibitsA-3 and C-4)
- An Admission History and Physical Examination indicated that the Patient’s blood pressure was 185/99, oxygen level was 99% on room air, and she was wheezing upon expiration. (Exhibit A-2)
- In the ER, the Patient was given nebulizers, prednisone, and one dose of azithromycin. (Exhibits A-4 and C-4)
- The ER physician determined that thePatient had not improved following the preceding medical treatment, therefore,he recommended that the Patient be admitted to the hospital. (Exhibit A-3)
- The Patient was approved by the hospital for admission at 10:30 PM on May 3, 2014, for COPD exacerbation. (Exhibits A-3 and A-4)
- An admission chest X-Ray showed that the Patient’s lungs were expanded and free of infiltrates and masses. (Exhibits A-4 and C-3)
- There were no consultations or procedures done during the course of the Patient’s admission. (Exhibits A-4 and C-3)
- On May 5, 2014, the Patient was stable, her breathing was better,she was able to walk without shortness of breath, and she was discharged to home with instructions to continue various medications. (Exhibits A-4 and C-3)
- On August 27, 2014, the Department sent a written Notice denying the Appellant’s
request for reimbursement because inpatient admission was not medically necessary.
(Exhibit C-4)
- On September 26, 2014, the Appellant filed an appeal with respect to the above Notice.
- The Patient did not meet InterQual criteria for an inpatient admission.
- The Department provided credible testimony that the Patient’s inpatient admission from
May 3, 2014 to May 5, 2014 was not medically necessary.
DEPARTMENT’S POSITION
The Department’sRepresentative testified that according to regulations at
55 Pa. Code§ 1101.1, “medically necessary” is defined as a service, item, procedure or level of care that is compensable under the MA Program, necessary to the proper
treatment or management of an illness, injury or disability, and prescribed, provided or ordered by an appropriate licensed practitioner in accordance with accepted standards of practice.The Department further testified that regulations also mandate that the amount of services rendered to a Patient may not exceed the Patient’s needs.He also testified that the medical record does not document why the Patient was admitted as an inpatient. He contended that the Patient’s oxygen level never fell below normal levels, and would have had to fall to 89% or less for her to be sick enough to be admitted. In addition, the Patient’s chest X-Ray indicated that she had no acute disease. The Department testified that the Patient never met the intensity of illness InterQual criteria to justify admission. The Department’s Representative contended that the services provided in this case could have been provided on an outpatient basis without undue risk to the Patient. Therefore, the Department correctly denied reimbursement, because inpatient admission was not medically necessary.
APPELLANT’SPOSITION
The Appellant’s Representative testified that InterQual criteria is not the final deciding factor in determining whether or not to admit a patient,but is a tool used in conjunction with the doctor’s assessment of the patient’s medical condition. In this instance, the Patient had other factors that the physicians took into account and treated her for.The Appellant’s Representative testified that the Patient was admitted for COPD with exacerbation. She also had high blood pressure and high glucose levels, due to her uncontrolled diabetes, and had some wheezing noted in her respiration. The Patient was given nebulizer treatments around the clock to prevent deterioration in hercondition, and also prednisone wasgiven orally for her COPD. Although theydid contribute to the elevation in her blood sugar results, the Patient was appropriately treated with steroids (prednisone). The Appellant’s Representative argued that inpatient admission was appropriate and necessary in order to monitor the Patient’s COPD, as well as address her elevated blood sugar and hypertension. For these reasons,reimbursement should be approved.
APPLICABLE LAW
55 Pa. Code § 1101.21. Definitions. provides in part:
Medically necessary—A service, item, procedure or level of care that is:
(i) Compensable under the MA Program.
(ii) Necessary to the proper treatment or management of an illness, injury or disability.
(iii) Prescribed, provided or ordered by an appropriate licensed practitioner in accordance
with accepted standards of practice.
55 Pa. Code § 1101.21a. Clarification regarding the definition of ‘‘medically necessary’’—statement of policy.
A service, item, procedure or level of care that is necessary for the proper treatment or management of an illness, injury or disability is one that:
(1) Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability.
(2) Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.
(3) Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age.
55 Pa. Code §1101.51(d) and (e)(1).Ongoing responsibilitiesof providers.
(d) Standards of practice
In addition to licensing standards, every practitioner providing medical care to MA recipients is required to adhere to the basic standards of practice listed in this subsection. Payment will not be made when the Department’s review of a practitioner’s medical records reveals instances where these standards have not been met.
(1)A proper record shall be maintained for each patient. This record shall contain, at a
minimum, all of the following:
(i) A complete medical history of the patient.
(ii)The patient’s complaints accompanied by the findings of a physical examination.
(iii)The information set forth in subsection (e)(1).
(2) A diagnosis, provisional or final, shall be reasonably based on the history and
physical examination.
(3)Treatment, including prescribed drugs, shall be appropriate to the diagnosis.
(4) Diagnostic procedures and laboratory tests ordered shall be appropriate to confirm or
establish the diagnosis.
(5)Consultations ordered shall be relevant to findings in the history, physical examination or laboratory studies.
(6)The principles of medical ethics shall be adhered to.
(e) Record Keeping Requirements and onsite access.
(1)General standards for medical records. A provider, with the exception of pharmacies, laboratories, ambulance services and suppliers of medical goods and equipment shall keep patient records that meet all of the following standards:
(i) The record shall be legible throughout.
(ii)The record shall identify the patient on each page.
(iii) Entries shall be signed and dated by the responsible licensed provider. Care rendered by ancillary personnel shall be countersigned by the responsible licensed provider. Alterations of the record shall be signed and dated.
(iv) The record shall contain a preliminary working diagnosis as well as a final diagnosis and the elements of a history and physical examination upon which the diagnosis is based.
(v) Treatments as well as the treatment plan shall be entered in the record. Drugs prescribed as part of the treatment, including the quantities and dosages shall be entered in the record. If a prescription is telephoned to a pharmacist, the prescriber’s record shall have a notation to this effect.
(vi) The record shall indicate the progress at each visit, change in diagnosis, change in treatment and response to treatment.
(vii)The record shall contain summaries of hospitalizations and reports of operative procedures and excised tissues.
(viii)The record shall contain the results, including interpretations of diagnostic tests and reports of consultations.
(ix) The disposition of the case shall be entered in the record.
(x) The record shall contain documentation of the medical necessity of a rendered, ordered or prescribed service.
55 Pa. Code §1101.66 (a).Payment for rendered, prescribed or ordered services.
The Department pays for compensable services or items rendered, prescribed or
ordered by a practitioner or provider if the service or item is:
(1)Within the practitioner’s scope of practice.
(2)Medically necessary.
(3) Not in an amount that exceeds the recipient’s needs.
(4) Not ordered or prescribed solely for the recipient’s convenience.
(5) Ordered with the recipient’s knowledge.
55 Pa. Code §1163.51(f).General payment policy.
(f)The Department does not pay for an admission that it determines is not medically necessary.
55 Pa. Code §1163.59. Noncompensable services, items and outlier days.
(a)The Department does not pay hospitals for an inpatient hospital stay if the admission
is directly or indirectly related to the hospital’s provision of:
(3)Medical or dental services or surgical procedures performed on an inpatient basis which could have been performed in an outpatient department, or practitioner’s office—for example, unilateral or bilateral myringotomy, vasectomy, blood transfusions, chronic maintenance hemodialysis, treatment for chronic pain and dental procedures which may be provided in an outpatient setting without undue risk to the patient.
(7)Diagnostic tests and procedures that can be performed on an outpatient basis and diagnostic tests and procedures not related to the diagnoses that require that particular inpatient stay.
(b)The Department does not pay for an inpatient hospital stay if the admission is not certified under the Department’s DRG review process.
55 Pa. Code § § 41.153. Burden of proof and production.
(a) Except as provided in subsection (b), the provider has the burden of proof to establish its case by a preponderance of the evidence and is required to make a prima facie case by the close of its case-in-chief.
ANALYSIS AND CONCLUSION
The Appellant’s Representative argued that the hospital appropriately admitted the Patient in order to monitor her COPD condition, and also treat her hypertension and elevated blood sugar levels present due to her uncontrolled Type 2 diabetes. The Appellant’s Representative argued that inpatient admission was required in order to provide round-the-clock monitoring and prevent further deterioration in the Patient’s condition. Forthese reasons,that the hospital should receive approval of payment for the days of inpatient admission.
The Department’sRepresentative contended that inpatient care is not reimbursable when it is not medically necessary, and that a lower level of care would have been appropriate for thePatient, either an observation or outpatientbasis level of care. He testified that InterQual acute adult criteria for COPD-related persistent shortness of breath despite 3 or more doses of medication, also requires an oxygen saturation level less than 89%. (Exhibit C-2, page 29) However, the medical record documents that the Patient’s oxygen saturation level was never 89%. The record indicates it was 99% on room air in the ER and her saturation levels remained high throughout admission. (Exhibit C-4, page 53) The chest X-Ray in the ER also indicated that the Patient’s lungs were clear and that the Patient had no acute disease. (Exhibit C-4, page 56) The Department argued that inpatient servicesin this case, were not medically necessary. Since the Department does not pay for services that are not medically necessary, the Department correctly denied the claim.
According to regulations, the Department pays for compensable services rendered, prescribed, or ordered by a provider only when the services are medically necessary. Regulations at 55 Pa. Code §§ 1101.51 (e)(1)(x) and 1163.75(5)(vi)require the provider to submit a record containing documentation of the medical necessity of a rendered service and need for admission.While it is true that InterQual criteria is not the sole deciding factor in whether admission is appropriate, in this case, the Appellant’s Representativefailed to meet the burden to establish her contention that inpatient admission was the correct determination. (55 Pa. Code § 41.153) Based on the medical record and the treatment provided, theDepartment correctly determined that the services provided could have been performed at a lower level of care, either on an observational or outpatient basis, without risk or harm to the Patient. As a result, this admission does not meet the level of care medically necessary to justify an inpatient admission pursuant to 55 Pa. Code§ 1163.59 (a)(2)(7).
Therefore, because the Department pays only for an admission that is considered medically necessary, the Department was correct in denying payment for the admission in question. Accordingly, the appeal of the Appellantisdenied. A Recommendation to the Chief Administrative Law Judge will be made consistent with these findings and conclusions.
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