Inpatient Admission and Continued Stay Review Overview:
As determined by the Alabama Medicaid Agency (AMA), random sample case selection is performed quarterly from the monthly file extracts provided to AFMC by AMA. The case selection process generates a list of cases selected for each hospital that is included in the quarterly data. Case selection lists are mailed to individual hospitals with record copy submission instructions and time frames. The case selection lists provide case identification sufficient to facilitate hospital medical record retrieval.
AFMC accepts medical record copies via regular mail, facsimile, CD, or HIPAA-compliant encrypted e-mail. AFMC also works with individual hospitals that are capable of providing electronic access to the requested records as long as this access is HIPAA compliant. Hospitals are required to provide copies of, or access to, the entire medical record of the cases selected.
Upon receipt, the Review Coordinator performs first-level full case review, comparing chart documentation to Alabama Medicaid’s Adult and Pediatric Inpatient Care Criteria, to determine if the admission and entire length of stay meet medical necessity requirements and to determine the appropriateness of the care provided. If medical necessity requirements are met and no quality-of-care concerns are identified, the Review Coordinator approves the case.
Cases that do not meet criteria requirements for admission or continued stay, or that have potential quality-of-care concerns are summarized and referred to Alabama contract physicians for a medical determination regarding the areas of concern. All instances of identified medically unnecessary admissions, medically unnecessary inpatient days, and confirmed quality of care concerns are reported to the Agency each quarter.
During the course of the AFMC review, Alabama Medicaid inpatient admissions are also evaluated to ensure that the requirements specified in 42 CFR 456 Subpart C – Utilization Control are met. All identified deficiencies are summarized and included in the quarterly reports submitted to the Agency.
In addition, selected cases are screened for incorrectly paid days. This may include wrong admission dates, days billed as acute when ordered observation, days billed when the patient was not at the facility, or other billing errors. These identified occurrences are also reported to the Agency each quarter.
Reimbursement for Medical Record Duplication
All providers, upon either verbal or written request from Alabama Medicaid Agency (AMA) or Arkansas Foundation for Medical Care (AFMC), the AMA Inpatient Hospital Quality Assurance Program contractor, shall furnish free of charge a copy of any requested record. If the provider has no copies, the provider must allow the person requesting the copy to check out the original for copying. The provider may require that a receipt be given for any original record removed from their premises.
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