Empire Suspends Certain Authorization Requirements to Aid NYS COVID-19 Response

Empire BlueCross BlueShield (“Empire”) is closely monitoring COVID-19 developments and what it means for our customers and our healthcare provider partners. With more than 37,000 people testing positive for COVID-19 in New York, demand for inpatient hospital services will increase greatly. As a result, the New York Department of Financial Services (DFS) has issued a circular letter dated March 20, asking all insurers to suspend certain utilization management review and notification requirements to free up staff for clinical support.  Effective March 20, Empire has implemented the following for Individual, employer-based fully-insured and self-insured (ASO)*, Medicare** and Medicaid plans:

 

Suspension of Preauthorization Requirements for Scheduled Surgeries or Admissions at Hospitals 

Empire is committed to working with and supporting hospitals. As of March 20, Empire is removing prior authorization requirements for scheduled surgeries or admissions at hospitals for the next 90 days to allow hospitals to utilize needed staff in clinical roles. Hospitals should continue admission notification to Empire in an effort to verify eligibility and benefits for all members prior to rendering services and to assist with ensuring timely payments. Empire may review any applicable cases retrospectively upon the resumption of retrospective review.

 

Suspension of Concurrent Review for Inpatient Hospital Services 

Empire is suspending concurrent review requirements for 90 days effective March 20. Hospitals should continue admission notification to Empire in an effort to verify eligibility and benefits for all members prior to rendering services and to assist with ensuring timely payments. This will reduce the amount of communication with Empire to allow hospitals to focus on patient care. Empire shall review any applicable cases retrospectively upon the resumption of retrospective review.

 

Suspension of Retrospective Review for Inpatient Hospital Services and Emergency Services at In-Network Hospitals and Payment of Claims

Empire is suspending retrospective reviews for inpatient hospital services and emergency services provided at in-network hospitals for 90 days. The effect of this change is these claims will be paid without being reviewed for medical necessity for 90 days effective March 20. The Circular Letter explains that hospitals should not enforce any contractual limitations regarding the permissibility of retrospective review or overpayment recovery.

 

Hospital Discharge Planning and Preauthorization for Home Health Care and Inpatient Rehabilitation Services Following an Inpatient Hospital Stay

In an effort to allow hospitals to increase inpatient capacity by quickly discharging patients to subacute or home settings, Empire is suspending for 90 days preauthorization requirements for home health care services and inpatient rehabilitation stays (including inpatient rehabilitation services for mental health or substance use disorder treatment) following an inpatient hospital admission. Home health care services may be reviewed concurrently and retrospectively. This applies to concurrent and retrospective reviews for home health care services. This will allow members to be discharged more quickly and into services that will aid in their recovery from inpatient services. Hospitals must make every effort to transfer patients to in-network rehabilitation facilities. Empire shall review any applicable cases retrospectively upon the resumption of retrospective review.

 

Notification Requirements for Emergency Hospital Admissions 

Empire is suspending requests for medical records as part of the notification for emergency hospital admissions for 90. Hospitals should continue admission notification to Empire in an effort to verify eligibility and benefits for all members prior to rendering services and to assist with ensuring timely payments.

 

Issuer Audits of Hospital Payments and Overpayment Recovery

Empire is suspending for 90 days non-essential audits of hospital payments. This will allow hospitals to focus on patient care during this crisis. The Circular letter indicates that Hospitals should toll contractual time limits on audits and overpayment recoveries while these audits are suspended.

 

* Because ASO plans are not insured, these customers have the option to opt out of the following provisions if they so choose.

 

** For Medicare plans, please note:

• A shorter timeframe or changes in action may be necessary where required by federal law.
• Medicare reserves the right to perform post-payment reviews for all services.
• Medicare Appeals timeframes are dictated by CMS.
• Audits/Recovery: Medicare is exempt from that statement.