RO Procedures for First-Time Exclusion of Hospitals and Units

3112.1 - RO Procedures for First-Time Exclusion of Hospitals and Units (Rev. 1, 05-21-04) When considering a hospital or hospital unit for exclusion for the first time, the RO has the SA and or the intermediary verify the facility’s compliance with exclusion criteria, as follows: • Psychiatric Hospitals - The RO verifies through a review of records that the hospital currently participates in Medicare as a psychiatric hospital, and that the hospital’s provider number identifies it as a psychiatric hospital. The hospital is not required to make a separate request for exclusion. • Rehabilitation Hospitals - The RO has the SA verify that the exclusion criteria in §3104 are met. As noted in §3108, a rehabilitation hospital may be presumed to meet certain criteria based on accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF) or by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). However, the SA should verify compliance with the medical director requirement, and the intermediary should verify compliance with the 75 percent rule for hospitals other than new hospitals. • Children’s Hospitals - The RO has the intermediary verify that the hospital has in effect an agreement to participate as a hospital and that a majority of the hospitals inpatients are individuals under the age of 18. The determination is to be based on the hospital’s most recently filed cost report, unless there is an indication that the age of the patient population has changed since the close of the period covered by the report. If the age of the patient population has changed since that period, the RO has the intermediary determine whether the age criterion is met by the patient population treated during the prior 6-month period. The intermediary may base the determination either on its knowledge of the provider or on a separate contact that results in an actual review of a sample of patient records. • Long-term Care Hospitals - The RO has the intermediary verify that the hospital has in effect an agreement to participate as a hospital and that the average length of inpatient stay is greater than 25 days. The average length of inpatient stay is to be computed by dividing the number of total inpatient days (less leave or pass days) by the number of total discharges for the hospital’s most recent complete cost reporting period. However, if a change in the hospital’s average length of stay is indicated, the hospital’s average length of stay is to be computed by the same method for the immediately preceding 6-month period. Rehabilitation hospitals meeting the length-of-stay criterion for exclusion as a long-term hospital are to be excluded as long-term hospitals, and should not be evaluated for exclusion under the rehabilitation hospital criteria. (See §3104). • Psychiatric Distinct-Part Units - The RO has the intermediary verify that the general criteria for exclusion for units in §3106 are met. The RO has the SA verify that the specific criteria for psychiatric units in §3106 are met. • Rehabilitation Distinct-Part Units - The RO has the intermediary verify that the general criteria for units in §3106 are met. The RO has the SA verify that the exclusion criteria in §3104 are met. As noted in §3108, a rehabilitation hospital may be presumed to meet certain criteria based on accreditation by CARF or by JCAHO. However, the SA should verify compliance with the medical direction requirement and the intermediary should verify compliance with the 75 percent rule for rehabilitation distinct-part hospital units other than new units. • Cancer Hospitals - The RO contacts the Center for Medicare Management to obtain a listing of the hospitals that have been designated as cancer hospitals.