After an emergency patient is stabilized, the next question is who pays for the care that follows. Post stabilization review is the process of requesting and tracking authorization for that care while the patient is still in the hospital. For Medicare Advantage enrollees, a federal rule sets out when the plan is responsible, and it runs on a one-hour clock. This guide explains that rule in plain terms. It is a general summary, not legal advice, and other payors follow their own contracts and state rules.
What Counts as Post-Stabilization Care
Under 42 CFR §422.113, post-stabilization care services are covered services, related to an emergency medical condition, that are provided after the enrollee is stabilized in order to maintain the stabilized condition and, in certain circumstances, to improve or resolve it[1].
When a Medicare Advantage Plan Is Responsible
The plan is financially responsible for post-stabilization care, inside or outside its network, in three situations[1]:
- The care was pre-approved by a plan provider or another plan representative.
- The care wasn't pre-approved, but it was administered to maintain the stabilized condition within one hour of a request to the plan for pre-approval of further post-stabilization care.
- The care wasn't pre-approved, but it was administered to maintain, improve or resolve the stabilized condition because the plan did not respond to a request within one hour, could not be contacted, or its representative and the treating physician could not reach an agreement and a plan physician was not available for consultation.
In that last situation, the plan must give the treating physician the opportunity to consult with a plan physician[1].
Real-Time Utilization Management for Post Stabilization Review
bServed's 24/7 post stabilization review services manage post-stabilization authorization requirements in real time, cover in-network and out-of-network patients, monitor level of care as clinical status evolves, and coordinate with payor case managers on complex continued-stay scenarios.
Hospital Authorization Management and Inpatient Authorization Follow-Up
Documentation is what protects the hospital if payment is disputed later: the time of each request, the response, and any escalation. bServed's hospital authorization management includes same-day follow-up when decisions are pending, immediate escalation when an authorization is delayed or at risk, and expiration tracking across active authorizations. That inpatient authorization follow-up continues once the patient is admitted, alongside daily inpatient concurrent review services.
Outsourced Post Stabilization Review
Hospitals outsource post stabilization review to get round-the-clock coverage and dedicated reviewers without building the program in house. bServed's published figures show 60% lower in-house UM costs, and implementation is typically complete within 30 days. See Outsourced Utilization Management: When It Makes Sense for a Hospital for the decision framework, and How to Choose a Utilization Management Company for what to ask.
Where It Fits in the Stay
Post stabilization review follows emergency department utilization review and leads into concurrent review once the patient is admitted. For the ED side, see Emergency Department Utilization Review: What Happens Before the Admit Decision.