Hospitalization: legal profiles, discipline and administrative practice

Introduction

Within the realm of legal institutions related to illness — defined as “the alteration of health status or the presence of injuries that result in temporary incapacity for work” (Art. 2110 of the Civil Code) — hospitalization is also included. Hospitalization, which in practice represents the period during which a patient is hosted at hospital facilities to treat illnesses that require interventions not feasible on an outpatient basis, may initially appear similar to the institution of illness, as it is effectively a derivative of it. However, hospitalization presents several management and administrative challenges that differ from the ordinary handling of illness.

This document aims to examine the institution of hospitalization from various perspectives to highlight the complexities — primarily administrative — that arise in cases of illness leading to hospitalizations. The analysis starts with the legal framework, continues with the responsibilities that fall on the worker and healthcare staff (as additional stakeholders in hospitalization cases), and concludes with the financial treatment applicable in hospitalization cases.

When we can speak of hospitalization

To properly frame the institution of hospitalization, it is first necessary to analyze the legal definition provided by the legislator, distinguishing it — at least from a formal point of view — from other areas of activity offered by hospital care, such as emergency room access, day service, day hospital, etc.

Indeed, the legislator makes a clear distinction between the two cases:

• -For “Hospitalization” –> this refers to healthcare services in ordinary hospitalization guaranteed to individuals who, in the presence of acute problems or conditions, require prolonged medical and nursing assistance and observation throughout the day for at least 24 hours (Art. 38 of DPCM January 12, 2017);
• -For “Day Hospital” –> this refers to programmable healthcare services from different specialized fields, aimed at addressing acute conditions or problems requiring diagnostic assessment… not feasible in an outpatient setting. Day hospital activity consists of one or more limited-duration visits during part of the day, without the need for an overnight stay (Art. 42 of DPCM January 12, 2017).

Therefore, based on the above legal definitions, hospitalization is characterized by a duration of at least 24 hours and requires an overnight stay within the healthcare facility. Conversely, day hospital care has a daily duration, without an overnight stay, and involves “one or more limited-duration visits, even for only part of the day.”

Regarding the distinction mentioned above, which aims to immediately clarify the clear difference between the institutions in question, it is known that collective bargaining agreements sometimes equate the two institutions in terms of absences that affect the calculation of the protected period and the economic treatment (see Art. 70 of the CCNL Carta – Industria; Art. 2 of the CCNL Metalmeccanica – Industria).

In addition to the cases mentioned above, there is the possibility for the worker to take time off for “emergency room access.” This case has the same characteristics as hospitalization and must therefore be considered for social security protection, where applicable, and the related medical certification to be produced. Thus, when treatments or the simple case of “brief observation” in the emergency room require an overnight stay, the same discipline as hospitalizations must be applied under the social security protection for illness (INPS, message no. 1074/2018). Otherwise, if there is no overnight stay, the event will be entirely treated as an illness, both from an economic treatment perspective and in terms of the certification of absence through the transmission of the appropriate electronic illness certificate with a protocol number (INPS, message no. 1074/2018) issued by the worker’s primary care physician.

Procedural and administrative aspects

Unlike illness cases, where the procedure involves

a) the obligation for the attending physician to electronically transmit the illness certificate to INPS through the appropriate channels (D.M. April 18, 2012); b) the responsibility of the worker to communicate the protocol number of the certificate to the employer.

the procedures for hospitalization cases require different and, in some cases, greater diligence and attention, both from healthcare facilities and the worker.

This takes on even greater importance regarding the accurate tracking of such absences for calculating the protected period and the financial implications of illness periods, which may differ in some cases from what is defined by collective bargaining agreements (e.g., Art. 187 of the CCNL Terziario – Confcommercio states that hospitalization days do not negatively affect the reduction in payment during the waiting period).

The guidelines on procedural aspects and the deadlines for submitting hospitalization, day hospital, and emergency room access certificates are defined by INPS Circular No. 136/2003.

First, regarding hospitalization days and/or the day emergency room care was provided, INPS requires hospitals to submit the related certification through electronic channels.

In cases where electronic submission is not possible — a scenario that occurs frequently — hospitals are required to issue a paper certificate necessary for recognizing the right to benefits.

This document, as referenced in INPS Circular No. 136/2003, must necessarily include the following elements:

• the hospital’s letterhead where the hospitalization occurred;
• the patient’s (worker’s) details;
• the date the certificate was issued (typically coinciding with the patient’s discharge);
• the admission and discharge dates;
• the readable signature of the doctor and/or medical staff;
• the diagnosis.

In the absence of electronic submission, this document must be subsequently sent by the worker to the territorially competent INPS office via registered mail with return receipt within one year of the event. Simultaneously, a copy without the diagnosis must be provided to the employer.

Given the above, it is clear that this procedure can create administrative complications, as the responsibility for presenting both the paper hospitalization certificate to INPS and the employer falls solely on the worker.

Indeed, it often happens that the worker, for various reasons, does not transmit the paper certificate to INPS, directly resulting in the institution having no record of the days the worker was absent and for which the employer must reconcile the sums related to the advance payment of benefits on behalf of the institution.

Secondly, in cases where healthcare facilities correctly submit electronic hospitalization certificates, the responsibility lies with the healthcare staff to

• correctly classify the type of hospital care provided (hospitalization, day hospital, emergency room access);
• precisely report the admission and discharge dates on the hospitalization certificate.

Regarding point 1), it often happens that the assessment of the type of care provided is carried out by individuals who are frequently lacking specific knowledge in the field, assigning incorrect labels to the absences (e.g., hospitalization instead of illness), causing issues in managing the absences and affecting the institution’s controls.

Indeed, only with an electronic certificate that meets the provisions of D.M. April 18, 2012, can the event be properly managed. Otherwise, if, despite an overnight stay in the emergency room, no hospitalization certificate is issued but rather an illness certificate (as often happens in practice), to properly handle the event, the worker must provide additional documentation for the investigation, sending it to the relevant INPS office and the employer — in cases where the illness benefit is advanced — which clearly shows the extended stay in the emergency room. This makes the entire process even more complex and uncertain (INPS, message no. 1074/2018).

Additionally, of utmost importance is the accurate indication of the day on which the discharge procedures are carried out. This day should not be included in the period reported in the electronic hospitalization certificate but should instead coincide with the first post-hospitalization illness day.

It is thus clear that there is a fine line separating the institutions of hospitalization and illness, particularly in cases of emergency room access, where proper management and “communication” to INPS are left exclusively to the healthcare staff, unaware of the administrative consequences that presenting an electronic illness certificate instead of a hospitalization certificate can have on personnel management within companies. These issues can even lead to calculation errors regarding the protected period, potentially affecting the legitimacy of dismissals for exceeding it.

Similarly, to point 1), the responsibility in point 2) also has repercussions on personnel management within companies. When the electronic hospitalization certificate is submitted, the healthcare staff is required — as previously mentioned — to indicate both the start and end dates of the hospitalization. In the day-to-day management of hospitalization events, this rarely happens, and the healthcare staff transmits to INPS a hospitalization certificate with a start date but without any end date, causing complications both in managing the financial treatment of the days to be treated as hospitalization and in justifying the worker’s absence.

In common practice, what often happens is that the healthcare staff of hospitals issues a subsequent illness certificate (presumably for the discharge day and the subsequent recovery period) that traditionally “closes” the previous hospitalization period, which, as mentioned, does not report any discharge date. This results in the payment of full INPS benefits from the first illness day onwards. If this is true, it is equally true that among the worker’s recorded absences, there are unjustified days between the hospitalization start date and the subsequent illness start date.

These errors directly aggravate the administrative burden of managing the aforementioned days by companies, as the latter must verify that the worker was indeed hospitalized on those days, excluding an early discharge, and ensure that the subsequent illness period cannot be classified as a relapse (which, as known, has different financial treatment).

Financial treatment of hospitalization

With specific reference to the financial treatment of hospitalization, several legislative interventions have followed, modifying the economic discipline of hospitalization itself and related cases, such as “Day Hospital,” which, from an economic point of view, is treated similarly to hospitalization.

Below are the economic treatments for the various hospital care activities, as modified by the most recent administrative practices:

1. Hospitalization –> During hospitalization periods, understood as stays in hospitals lasting at least 24 hours, workers are entitled to the following benefits (INPS, circular 134368/1981):

i. For workers with dependents (Art. 12, para. 2 of D.P.R. 917/1986): it amounts to 50% of the average daily wage (RMG) for compensable days from the 4th to the 20th day of illness and 66.66% of the RMG from the 21st day onwards; ii. For workers without dependents: the daily allowance is 2/5 of the above amounts, i.e., 20% from the 4th to the 20th day and 26.66% from the 21st day onwards.

2. Emergency room access –> for this case, as mentioned in the previous paragraph, the economic treatment differs based on whether or not the worker stays overnight in the hospital, and indeed:

i. If there are situations requiring an overnight stay in the emergency room, the allowance to be paid (and the related certificate) follows the hospitalization provisions outlined in point 1) above (INPS, message no. 1074/2018); ii. Whereas if the situation is resolved with the discharge of the patient without an overnight stay in the emergency room, the allowance to be paid — as well as the electronic certificate to be transmitted — is the one related to illness, as outlined in point 1) above (INPS, message no. 1075/2018).

3. Day Hospital –> in the case of duly documented services performed in day hospital, the requirement of being unable to work, necessary for the event to be compensable, can only be deemed met when the daily stay at the treatment facility covers the full working day or, if the stay is shorter, when, medically, the worker is deemed incapable of working during the same day as the treatment (INPS, circ. no. 136/2003). Once the minimum stay requirement at the treatment facility is met, the applicable financial treatment is the same as for hospitalization as outlined in point 1), including the reduction in benefit for workers without dependents.

Relevance of hospitalization for the protected period

As mentioned in the previous paragraphs, the attribution of hospitalization status to emergency room access or day hospital cases has direct consequences both for certification requirements and financial treatment. However, the impact of an incorrect classification of illness days is most significant regarding the protected period. In this regard, most collective bargaining agreements exclude certified hospitalization days from the calculation of illness days that count towards exceeding the protected period, as shown in the table below:

Therefore, considering the above, it is clear that — for example, in the context of assessing dismissal for exceeding the protected period — counting more or fewer illness days is extremely significant, especially regarding the legitimacy of the potential dismissal. In this regard, administrative diligence is particularly crucial, first on the part of healthcare staff in transmitting certificates, but also on the employer’s part, within the boundaries of privacy regulations, in verifying the accuracy of the medical certificate on the official INPS website compared to the actual event that occurred.

We remain available for any further discussion deemed appropriate.