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CMS Paid $4M in Excess GME Medicare Reimbursement, OIG Finds

CMS did not have adequate procedures to ensure that hospitals did not count residents as more than one FTE when claiming GME Medicare reimbursement, audits showed.

Graduate Medical Education (GME) Medicare reimbursement

Source: Thinkstock

By Jacqueline LaPointe

- Audits performed by the HHS Office of Inspector General (OIG) showed that hospitals received excess Graduate Medical Education (GME) Medicare reimbursement after counting residents and interns as more than one full-time equivalent (FTE).

CMS is responsible for ensuring hospitals comply with federal requirements when claiming GME Medicare reimbursement. The supplemental payments offset the costs of educational activities incurred by hospitals participating in Medicare.

Hospitals claim the GME reimbursement based on the number of FTE residents that the facility trains and the portion of time those residents spend practicing at the facility. But if a resident works at more than one hospital, the resident only counts as a partial FTE at the claiming hospital and that hospital cannot claim the time a resident spent training at another facility.

Additionally, a resident cannot be countered as more than one FTE according to federal requirements for GME Medicare reimbursement.

In seven of eight audits, however, the OIG found cases in which teaching hospitals did not comply with federal requirements for GME Medicare reimbursement.

Specifically, hospitals in six of the twelve Medicare Administrative Contractor (MAC) jurisdictions studied claimed GME reimbursement for residents who were claimed by more than one hospital for the same reporting period. The federal watchdog also identified instances in which residents counted as more than one FTE.

The excess GME Medicare reimbursement totaled almost $4 million from 2006 to 2013, the OIG reported.

CMS overpaid for educational payments because the federal agency did not have “adequate procedures to ensure that hospitals do not count residents as more than one FTE,” the watchdog added.

For example, MACs did not always review data submitted by hospitals for the GME Medicare reimbursement. The contractors failed to review information submitted by hospitals through the Intern and Resident Information System (IRIS), a CMS software application that hospitals use to collect and report information on residents working in approved residency programs at teaching hospitals.

CMS stated that the agency instructs MACs to edit their databases containing IRIS data to guarantee that residents are not countered as more than one FTE. And if their edits show that hospitals are claiming a resident as more than one FTE, then the contractor should return the data to the reporting hospitals.

However, MACs in the OIG audits stated that their Statements of Work (SOWs) with CMS did not contain instructions on editing the databases with IRIS data. The SOWs also did not include the funding for analyzing IRIS data to ensure residents were not counted as more than one FTE.

The MACs explained that they only conducted limited reviews of IRIS data under “certain circumstances,” and additional procedures would be beyond the scope of their SOWs.

To ensure CMS is properly paying hospitals for GME Medicare reimbursement, OIG recommended that CMS implement polices and procedures that ensure no resident is counted more than one FTE. The policies and procedures should “analyze IRIS data or requiring MACs to determine if residents claimed by hospitals in their jurisdiction were claimed as more than one FTE,” the watchdog advised.

Implementing the polices and procedures across the 12 total MAC jurisdictions would significantly reduce costs for CMS.

“Because our audits covered only six MAC jurisdictions across various fiscal periods, we believe that, if CMS took steps to ensure that all MAC jurisdictions implemented procedures, it could achieve significant cost savings,” the OIG wrote.

In response to the OIG’s findings, CMS agreed with the recommendations and explained that the agency has started to implement a new national IRIS database. The new database should help to ensure no resident is counted as more than one FTE, the agency reassured.

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