Colorado Medical Society

WHEREAS, the problem of health plans and third party payers arbitrarily changing a patient's status from inpatient to observation when admitted to the hospital is growing, and

WHEREAS, the American Medical Association has developed policy and guidelines on this issue that could alleviate the problem, therefore be it

RESOLVED, that the Colorado Medical Society adopt AMA Policy H-160.944 "Defining Observation Care", which reads as follows:

(1) The CMS will work with third party payers to establish a uniform definition of "observation care", including the following:

(a) The patient should be designated as under "observation care"

if the physician's intent for hospital stay is less than 24 hours. If the physician's intent and expectation is for a hospital stay of greater than 24 hours, then the stay should be considered inpatient. The use of 24 hours as a threshold for observation is a guideline. It is not unusual for observation to extend a few hours beyond 24 hours or for patients to be admitted to inpatient status before 24 hours.

(b) Patients classified as under "observation care" require hospital

level-of-care.

after initial physician evaluation of the patient's signs and

symptoms and appropriate testing. Post day surgical patients

should be registered as under "observation care" if, after a normal recovery period, they continue to require hospital level-

of-care as determined by a physician.

(2) The CMS will establish policy on "observation care" and

develop model legislation to ensure that:

(a) After initial approval of inpatient admission by insurers, there

should be no retrospective reassignment to "observation care"

status by insurers unless the original information given to

insurers is incorrect.

(b) Insurers should provide 60 days prior notice to providers of

changes to "observation care" criteria or the application of those

criteria with opportunity for comment. There should be no

implementation of criteria or changes without first following these

protocols.

administrative appeal process to deal with all utilization and

technical denials within a 60 day time frame for final resolution.

An expedited appeal process should be available for patients

in the admission process, allowing for a decision within 24

hours.

(d) Insurers and HMOs should provide clearly written

educational materials on "observation care" to subscribers

highlighting differences between inpatient and "observation

care" benefits and patient appeal procedures.

(Res. 808, I-95); and be it further

FISCAL IMPACT: None

RESOLVED, that the Colorado Medical Society reafirms that only the attending physician can change the patient's status under the Medical Practice Act.