March 29, 2023

Top Questions from the IME & GME Reimbursement Webinar

Tim Powell

Looking for more information about IME and GME Reimbursement? BESLER’s Senior Reimbursement Consultant Tim Powell answers your questions from the recent webinar.

To watch Tim’s IME & GME Reimbursement Webinar, click HERE.

Shouldn’t the prior year & penultimate counts be the ‘allowable’ count and not the actual counts meaning if your counts are over the caps, your counts would be the case?
Yes. For WS E Pt A you will need to use the allowable FTE Count from prior year and penultimate year from the Form 2552-10 line 12 (per Form 2552-10 Instructions).
Which type of beds does Medicare exclude from the IME calculation?
All exempt units (ex. IPF, IRF, SNF, etc.) including Swing Bed days and any temporary COVID beds entered into service during the PHE period (Please see the CMS published FAQs and instructions for Form 2552-10.). You should use only the routine bed days from WS S-3 Part I line 14 Column 3 divided by the number of days in the MCR period (less any temporary COVID bed days as mentioned above).
PSYCH Affiliation Agreement: For a PSYCH Affiliation Agreement, where do you enter the FTE amount on Worksheet E-3; Part II?
Line 4 per the Form 2552-10 instructions. Be prepared to explain to the MAC the reason for the FTE Cap adjustment (have a copy of your Affiliation Agreement handy).
Are most MACs requesting the Medical School diplomas during Audit in order for facilities to claim the FTEs?
No.
Can you explain what happens when a cap share specifies IME or GME only?

This would depend on your agreement and the interpretation of the MAC.
Can you further explain S-2 beginning line 64? The instructions mention base year beginning on or after July 1, 2009, and before June 30, 2010, not the 1996 reference. Is this the section you were referencing for the base year?

Prior to 2010, providers could not count time residents spent in non-provider settings. This comes from 5504 of the ACA.
Do you have to claim residents if you have them cycle through your hospital?
Typically, yes. Where the rotation is done is how the resident’s time is determined to be counted. I would think you would want to count it at your facility especially if the resident’s specialty is podiatry or dentistry and is an add-on to the cap. Please see the CMS Published FAQs for the PHE as there were provisions made for residents who rotated to non-sponsoring facilities to treat COVID patients.
During the pandemic, some beds were used for COVID-19 patients. Do you count those converted beds in the bed count?
No. CMS has instructed facilities not to count these beds for the IME Intern to Bed Ratios in the CMS published FAQs during the PHE period and the instructions to Form 2552-10.
Explain cap share agreements, especially when only IME or GME is included, but not both.
The requirements for an Affiliation agreement can be found at 42 CFR § 413.75. In essence, Medicare GME affiliation agreement means a written, signed, and dated agreement by responsible representatives of each respective hospital in a Medicare GME affiliated group, as defined in this section, that specifies –

(1) The term of the Medicare GME affiliation agreement (which, at a minimum is 1 year), beginning on July 1 of a year;

(2) Each participating hospital’s direct and indirect GME FTE caps in effect prior to the Medicare GME affiliation;

(3) The total adjustment to each hospital’s FTE caps in each year that the Medicare GME affiliation agreement is in effect, for both direct GME and IME, that reflects a positive adjustment to one hospital’s direct and indirect FTE caps that is offset by a negative adjustment to the other hospital’s (or hospitals’) direct and indirect FTE caps of at least the same amount;

(4) The adjustment to each participating hospital’s FTE counts resulting from the FTE resident’s (or residents’) participation in a shared rotational arrangement at each hospital participating in the Medicare GME affiliated group for each year the Medicare GME affiliation agreement is in effect. This adjustment to each participating hospital’s FTE count is also reflected in the total adjustment to each hospital’s FTE caps (in accordance with paragraph (3) of this definition); and

(5) The names of the participating hospitals and their Medicare provider numbers. We have noted different MACS have different interpretations of approving cap share agreements and can not give a definitive answer without seeing the agreement and knowing what the MAC has allowed.
How are you handling instances where ECFMG issue dates were delayed due to COVID and the resident started training prior to the issue date? Are you claiming all of the training time from the start date or just from when the ECFMG was issued?
Per the CMS published IRIS instructions, “Effective June 14, 2004, FMSGs are required to pass Step 1 Clinical Knowledge (CK) and Step 2 Clinical Skills (CS) for certification from the ECFMG. Do not use either the issuance date or the English examination date on the ECFMG certificate as the certification date. Instead use the latest examination date of any other examination as the certification date. For example, if the FMSG passed the CK test on May 15, 2004 and the CS test on July 1, 2004, then the certification date is the later date of July 1, 2004.”
If the first year of the program, do you receive IME payment for general Medicare and Medicare Managed Care if it is a partial year?
In the first partial year, you receive cost reimbursement.
If there is an affiliation agreement with another hospital, can the hospital that does not pay the I&R salary claim the FTE?

Yes, or partially. The resident must be rotating to the facility that will claim the time. Also, please see the CMS Published FAQs for the PHE period as there were provisions made for residents who rotated to non-sponsoring facilities to treat COVID patients.
Is it possible to have your residency cap amended?

We have not heard of an instance where the MAC has amended an FTE Cap once the Cap has been established. If you are in the five year cap window and your FTE cap has not been fully determined, you may be able to work with the MAC to arrive at agreed upon cap.
Should we report all new residency programs on E Part A Line 6?
Yes. As long as the program meets the requirements for a new program under 42 CFR 413.79(e).
What date should go on the IRIS for ECMFC certificates? The date the certification was issued, or the date of last exam?
Per the CMS published IRIS instructions, “Effective June 14, 2004, FMSGs are required to pass Step 1 Clinical Knowledge (CK) and Step 2 Clinical Skills (CS) for certification from the ECFMG. Do not use either the issuance date or the English examination date on the ECFMG certificate as the certification date. Instead use the latest examination date of any other examination as the certification date. For example, if the FMSG passed the CK test on May 15, 2004 and the CS test on July 1, 2004, then the certification date is the later date of July 1, 2004.”
What is your process for determining if the hospital incurs all, or substantially all, of the costs for the training program in that setting?
Normally, it is the hospital pays for ~90% of the salaries, benefits and occasionally other subsidized costs. There must be a written agreement in place.