Inpatient Pre-Certification

NYCHSRO/MedReview’s URAC Accredited Pre-Admission/Concurrent Certification program helps helps reduce and avoid unnecessary health claim costs by monitoring the volume and appropriateness of services requested.

WHAT IT IS:

  • Reduces unnecessary hospital admissions by ensuring that only medically necessary admissions and procedures are certified.

  • Reviews the hospital stay to ensure that the continued hospitalization is justified.

  • “Flags” to claim’s payer any major or catastrophic events where payment may be extraordinary even though stay is certified (e.g., potential COB, Workers’ Compensation, or other subrogation; hospital preventable errors; inappropriate hospital readmission; etc.).

  • Identifies potentially complex or catastrophic cases for implementation of the Coordinated Care (Case Management) Program.

  • Reviews are performed by qualified personnel using nationally recognized criteria for utilization management.

HOW IT WORKS:

  • The patient or his/her physician calls NYCHSRO/MedReview and outlines the diagnosis, proposed course of treatment, planned procedures, anticipated dates and length of stay, and setting in which the care will be given.

  • Discussion may occur with the attending physician, allowing the physician input into the determiniation. A determination is made regarding the medical necessity of the admission and appropriate level of care.

  • The case is reviewed for medical necessity. Nationally recognized utilization criteria and plan benefit allowances are also considered when making determination.

  • If the inpatient admission is determined to be inappropriate, the reviewing physician may make treatment recommendations for alternative, more cost effective settings if indicated.

  • Written confirmation of the determination is forwarded to the hospital, patient and attending physician.

  • NYCHSRO/MedReview tracks the hospital stay, reviews additionally for concurrent requests and contacts the hospital to verify discharge of the patient.

For more information, click here.