150.995 Preadmission Review:
MSSNY is in agreement with the American Medical Association policy to oppose mandated blanket hospital preadmission review for all patients, or for specified categories of patients, by government, other payors or hospitals, while encouraging physician-directed peer review organizations to consider the implementation of focused preadmission review on a voluntary basis. The MSSNY promulgated the following sample Guidelines for all third party payors or insurers in the matter of preadmission certification and review in this State Preadmission Certification and Review Guidelines:
(1) The physician/patient relationship must remain intact and must not be disturbed by interference from any entity, including third party insurer.
(2) The quality of health care delivered must remain at the highest level and not be affected by health insurance mandated policies and procedures.
(3) There shall be direct and continuing communications by health insurers to physicians and insureds regarding prior authorization requirements; it shall be the responsibility of the insured or insurer to notify physicians when there are any pre-authorization or other technical contract requirements connected with the rendering of specific services.
(4) In situations where the diagnosis, proposed plan of treatment, and anticipated length of hospital stay is questioned, it must be discussed only between the treating physician and a physician representing the third party carrier.
(5) After thorough review of all submitted medical information, if the insurer’s physician disagrees with the certification request, be it the rule that the patient’s physician be allowed a consultation with the insurer’s consulting physician prior to any adverse decision. The attending physician should be given the opportunity to provide additional medical information to substantiate the request for hospital admission. If the patient’s physician disagrees with the initial consultation, be it the rule that a request for a second consultation be granted by the health insurer. (Under these circumstances, further monetary penalties, i.e., reduced benefits, should not be imposed on the insured because of physician’s request for a second consultant.) However, it is understood that reduced benefits may be imposed by the insurer if the patient does not adhere to the preadmission certification requirement to obtain a second opinion.
(6) Physician-to-physician contact be the rule when there is disagreement between a treating physician’s plan of treatment and insurance company guidelines. If there is a change of treatment plan, the insurer must give the treating physician ample time to notify his/her patient of such change. Further, where disagreement exists between the physician and the insurer as to anticipated length of stays and preadmission certification, ample time must be allowed for the attending physician to apprise the patient that his/her contract may or may not provide full benefits for the prescribed plan of treatment, and any ensuing costs for the services provided may become the patient’s responsibility.
(7) Since patients who inadvertently do not request required pre-admission and length of stay certification for services performed may be subject to reduced benefit payments, they must have right of appeal.
(8) When emergency hospitalization is required, up to 48 hours (i.e., two business days, following the patient’s admission) must be allowed for the purpose of certification.
(9) Health insurers must also be responsive to the desires of the State and local medical community concerning input into the establishment of criteria for preadmission certification programs.
(10) In view of the significant increase in New York State health insurance plans requiring Preadmission Certification Programs, salient features of these programs, such as second surgical opinions, concurrent length of stays, and confirmation of emergency admissions, be implemented uniformly in order to mitigate confusion among the patient and physician community in such a way as to conform to the basic principles outlined in the foregoing Guidelines. (HOD 1986-11; Amended Council 2/12/87; Amended HOD 3/14/87; Reaffirmed HOD 2013; Reaffirmed HOD 2023)
