Transfer and Discharge Refusals by Hospitalized Member
Provider Type
- Physicians
- Hospitals
- Participating Physician Groups (PPG)
- Ancillary
Participating Facility
Health Net recommends the following procedure to protect the participating physician group (PPG) and Health Net from liability in cases where a member or the admitting physician at a nonparticipating facility within a 30-mile radius of the member's home refuses to allow a transfer or discharge. This procedure is applicable to either transfer refusal or discharge refusal:
- The PPG physician must contact the attending physician. As soon as the PPG is aware of the hospitalization, the PPG physician must advise the attending physician that transfer of the member to a participating facility must occur as soon as the condition is stable.
- If the attending physician refuses to transfer, the PPG physician must monitor the member's condition through the attending physician to determine when the member can be transferred to a participating facility.
- The physician, in conjunction with the PPG case manager, must collaborate with the attending physician to determine a facility appropriate for transfer. If indicated, an appropriate specialist must be identified to contact the attending physician at the current hospital to discuss the case and the member's stability for transfer.
- At times, Health Net may request that the member be transferred to an in-network facility. If the accepting physician (or specialist) and attending physician agree that the member is stable for transfer and a bed is available at the accepting facility, but the attending physician refuses to transfer, the PPG (or Health Net) must issue a facility non-payment letter advising the facility of non-payment, effective the date agreed upon by both physicians that the member was stable for transfer. Health Net and PPGs ensure that a participating physician is available 24 hours a day to authorize medically necessary post-stabilization care and coordinate the transfer of stabilized members in an emergency department, if necessary.
- Health Net does not cover continued hospitalization if the accepting physician (or matching specialist) and attending physician agree that member is stable for transfer and a bed is available at the accepting facility, but the member refuses to transfer. The PPG must issue a member denial letter for refusal to transfer (PDF). Member denial is effective 24 hours after the date the member receives the letter.
Transfer of Hospitalized Member to Participating Facility
A Health Net member may be hospitalized at an out-of-network facility for emergency care. A member affiliated with a capitated participating physician group (PPG) should be transferred to a PPG-participating facility as soon as the member's medical condition allows. For PPG responsibilities regarding non-participating hospitals refer to Shared Risk UM Responsibilities.
There are situations when a Health Net member is hospitalized in a non-participating facility within the PPG's service area. The member should be transferred to a facility inside the service area that contracts with the PPG as soon as the member's medical condition allows.