Rural Primary Care Hospitals: Experience Offers Suggestions for Medicare's Expanded Program
HEHS-98-60
Published: Feb 23, 1998. Publicly Released: Feb 23, 1998.
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Highlights
Pursuant to a legislative requirement, GAO reviewed the Rural Primary Care Hospital (RPCH) Program, focusing on: (1) assessing compliance with the requirements that RPCHs have an average length of stay of 72 hours or less and that physicians certify that inpatients are expected to be discharged within 72 hours; (2) assessing whether these two requirements affected the type of patients treated by RPCHs; and (3) comparing Medicare's cost for inpatient services in RPCHs to what those costs would likely have been in hospitals paid under the prospective payment system. GAO also looked at how the experience under the RPCH program could be used in implementing the expanded Critical Access Hospital (CAH) Program.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to establish a mechanism for ensuring that CAHs do not receive payment for inpatient cases that exceed the 96-hour length-of-stay maximum unless the responsible peer review organization (PRO) waives that limit and defines the conditions and circumstances under which it would be appropriate for PROs to waive the 96-hour limit. |
HHS agrees that fiscal intermediaries need to be instructed not to pay for inpatient CAH stays beyond the fourth day unless there is accompanying justification for the extended stay. HCFA established procedures for a peer review organization to follow before waiving the 96-hour stay limitation for a patient at a critical care hospital, which became effective May 3, 1999. HHS is also looking into the feasibility of providing more specific guidance as to what circumstances would justify extended stays.
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| Health Care Financing Administration | HCFA should establish a method to ascertain compliance with the requirement that physicians certify that patients are expected to be discharged within 96 hours of admission. |
HHS included instructions effective March 5, 1999, in the Medicare Hospital Manual, informing intermediaries that Medicare part A pays for inpatient CAH services only if a physician certifies that the individual may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH. This certification is required no later than 1 day before the date on which the bill for inpatient CAH services is submitted to the intermediary. HHS does not routinely require physician certifications to be submitted with inpatient bills; but they should be retained at the CAH and made available on request to the intermediary or the HCFA regional office.
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