The Island Peer Review Organization, Inc. is under contract with the United States Department of Health and Human Services to serve as the Peer Review Organization (PRO) for New York State. The purpose of this contract is to ensure that medical care rendered to Medicare beneficiaries is necessary, appropriate, and of good quality.
Medicare admissions to all hospitals in New York State are subject to review specified in a plan developed by the PRO and approved by the Federal Government. In most instances, this review will be performed retrospectively; this is, after your discharge from the hospital, determination will be made as to whether your hospital stay was appropriate for payment under the Medicare Program. A determination that all or any part of your hospitalization was not medically necessary or appropriate can only be made by a licensed, practicing physician acting on behalf of the PRO, and could result in the loss of Medicare payment to the hospital. You will not be held responsible for any loss of payment to the hospital resulting from retrospective review conducted by the PRO. All such determinations by the PRO will be communicated in writing to you, the hospital and the agency responsible for Medicare payment to the hospital.
|
|
In some instances, while you are still hospitalized, a determination may be made that the level of care and/or the services which you are receiving no longer meet criteria for coverage under the Medicare Program. This determination will be made by the physician responsible for your care and /or the Hospital Utilization Review Committee. In these instances the hospital may notify you or your representative that the care you are receiving is not covered under the Medicare Program. Such notification will also inform you of your responsibility for any financial liability incurred as a result of this determination and also your right to request a reconsideration.
Please be informed that the PRO requires that all hospitals submit certain billing and medical record information for Medicare patients. Regulations have been enacted protecting patient's privacy and confidentiality by restricting access to sensitive information and by coding patient and physician identifiers.
Should you have any questions regarding this notice or the review system, please contact the Case Management Department in the hospital or
Island Peer Review Organization
1979 Marcus Avenue
Lake Success, NY 11042
800-446-2447 or 516-326-6131
|
