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Day-of-Service Decision Making Hospital Initiative Fact Sheet

Description: Oxford Health Plan's medical management division re-engineered its hospital stay procedure to address the issue of retrospective denials. Working closely with major area hospitals and hospital associations, Oxford has developed what Dr. Alan Muney, M.D., Oxford's chief medical officer, has described as one of the best examples of consensus-based healthcare management. In implementing this first-to-market process, Oxford not only eliminates retrospective denials for "day of" services, but gives conditional certification for the next day, thus improving communication with Oxford's member hospitals.
Participants: New York, New Jersey and Connecticut member hospitals (approximately 200 hospitals)
Process:
•   Oxford's medical management team, comprised of doctors and registered nurses, and hospital case managers set a precise time each day to review the status of hospitalized members.
•   Each case is reviewed to determine day-of-service and prospective decision-making.
•   Oxford will notify the hospital verbally of all certified days, and will send a fax of all denied days. In both cases, a letter will be sent by 4 p.m. on all members discussed.
•   Oxford agrees to provide certification for all services that have been documented with necessary clinical information that demonstrates medically appropriate care.
•   Through this process, the hospital will not only know the status of same-day stays, but also can be pre-certified for the following day, with the necessary clinical information.
Advantages:
•   Hospitals know today about Oxford's preliminary decisions for tomorrow.
•   All pre-certified days are honored.
•   There are no retrospective denials, only retroactive approvals for days denied due to lack of clinical information.
•   Physicians and registered nurses do all reviews.
•   Only physician case managers can deny days.
Roll-out:
•   Pilot program begins May 3, 1999 with seven Westchester hospitals.
•   Long Island and New Jersey hospitals adopt program in mid-July.
•   Remainder of member hospitals in New York and Connecticut join program in late August 1999.

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