In compliance with state and federal regulations intended to contain hospital costs, your inpatient hospital stay is reviewed daily by the Care Management/Utilization Review nurses, and when necessary the Medical Director or the Utilization Review Committee.
Care Management/Utilization Review Team
The Care Management team will track your progress toward recovery. A case manager and/or social worker will assist you with discharge planning by making appropriate community services referrals or arranging for home medical equipment or extended care placement such as a nursing home.
The Care Management/Utilization Review team consists of you (the patient), your physician, your family and all participants involved in your care. We will work with your insurance carrier to provide for your healthcare needs. Our goal is to provide optimum coordination of all the services you require. You may contact the department directly by phoning extension 2932. Your family, your physician, or the nursing staff may also request assistance.
Medically Necessary Care
Insurance benefits, including Medicare and Medicaid, are limited to services that are approved as medically necessary, safe and appropriate for the acute inpatient hospital setting.
Services provided to patients beyond the date determined to be medically appropriate for discharge are the patient’s responsibility. If you are a Medicare patient and want to appeal this discharge decision, you can call Quality Insights of Pennsylvania at 1-800-322-1914. All other patients with Medicaid or commercial insurance will need to contact member services at the insurance company to request information regarding the appeal process.
If at any time during your stay it is determined that the kind of care you require should be provided elsewhere (in another healthcare facility, at home with assistance, etc.), you and your doctor will receive written notification that the admission or continued stay in the Hospital is no longer required for medical purposes.
Quality Insights of Pennsylvania (QIP) for Medicare patients, Department of Public Welfare for Medicaid patients and your commercial insurance companies all have similar requirements for medical necessity. Your record can be reviewed by the appropriate entity if care has been determined to be appropriate for another setting. Medicare, Medicaid and commercial insurance plans accept the dates determined as appropriate for discharge according to medical necessity criteria.
Remember, the Care Management/Utilization Review team’s goal is to ensure a smooth transition from the pre-admission process through inpatient hospitalization, discharge planning and post-hospital care.