Emergency Services Audits

Section 140 TITLE 89: SOCIAL SERVICES CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES SUBCHAPTER d: MEDICAL PROGRAMS PART 140 MEDICAL PAYMENT SECTION 140.31 EMERGENCY SERVICES AUDITS Section 140.31  Emergency Services Audits a)         All emergency services for which charges are made to the Department and are provided to a recipient who does not require admission as an inpatient are subject to audit. b)         An emergency services audit shall be limited to a review of records related to services rendered within three years of the date the hospital is notified that the audit will be initiated.  The Department shall notify the hospital of an audit at least four calendar weeks before the audit occurs, unless the hospital and the Department agree to schedule the audit at an earlier date.  The hospital's business and professional records for at least 12 previous calendar months shall be maintained and available for inspection by authorized Department personnel on the premises of the hospital.  Department personnel shall make requests in writing to inspect records more than 12 months old at least two business days in advance of the date they must be produced.  These records required to be maintained shall be kept in accordance with accepted business and accounting practice and shall be legible.  Such records must be retained for a period of not less than three years from the date of service or as provided by applicable State law, whichever period is longer, except that if an audit is initiated within the required retention period the records must be retained until the audit is completed and every exception resolved by settlement or by the Director's final decision. c)         All records required to be maintained shall be available for inspection by authorized Department personnel during normal business hours.  Department personnel shall make all attempts to examine such records without interfering with the professional activities of the hospital.  The hospital shall make legible copies of those records requested by the Department upon completion of its inspection, and tender said copied records to the Department within two weeks after such request is made unless this time is extended by mutual consent.  Additionally, if the hospital locates records that were unavailable during the audit, that data shall be submitted to the Department within 30 days after completion of the audit conducted on the hospital's premises, and that data shall be utilized in generating the audit findings. The determination that an emergency medical condition exists shall be based solely upon the review of the legible information contained in those medical records supplied by the hospital during the audit. d)         Authorized Department personnel shall meet with the chief executive officer of the hospital, or a person designated by the chief executive officer, upon arrival at the hospital to conduct the audit and at the conclusion of the audit.  The purpose of the pre-audit meeting shall be to inform the hospital of the scope of the audit.  The purpose of the post-audit meeting shall be to provide an opportunity for the auditors to discuss their preliminary findings with the chief executive officer, or a person designated by the chief executive officer.  More detailed audit findings shall be provided in writing to the hospital within 120 days after the date on which the audit conducted on the hospital premises was completed. e)         The final determination of whether an emergency room visit was for the alleviation of severe pain or for the immediate diagnosis and/or treatment of conditions or injuries which might result in disability or death if there is not immediate treatment shall be based upon the symptoms and condition of the recipient at the time the recipient is initially examined by the hospital's emergency department physician and not upon the final determination of the recipient's actual medical condition (see Sections 140.3 and 140.5 of this Part). f)         When the purpose of the audit is to determine the appropriateness of the emergency services provided, any final determination that would result in a denial of or reduction in payment to the hospital shall be based on the opinion of a physician licensed to practice medicine in all of its branches who is board certified in emergency medicine or by the appropriate health care professionals under the supervision of the physician. g)         The Department or its designated review agent in cases where the Department seeks to recover an extrapolated amount, shall use statistically valid sampling techniques when conducting audits as provided by Section 140.30 of this Part. h)         This Section shall not apply to any audits initiated prior to July 1, 1992.